Application for One Claim Program Instructions · Completethisapplicationeachpolicyyearofeligibleparticipation. · Completeallfieldsinthisapplication.BWCcannotprocessincompleteapplications. · Anofficer,partnerorownermustsignthisapplication. · Youmaysubmitthecompletedforminoneofthreewayslistedbelow. Online:www.bwc.ohio.gov Fax:614-621-1405 Mail:Attention:OneClaimProgram OhioBureauofWorkers'Compensation 30W.SpringSt.,22NDFloor Columbus,OH43215-2256 Employer information Name of employer and DBA Federal tax ID number BWC policy number Address City Employer contact for One Claim Program Email address for One Claim Program contact State ZIP code Title of the employer contact for One Claim Program Phone number Employers fax number ThisapplicationisfortheOneClaimProgram(OCP).Applicantsmustmeetalloftherequirementslistedbelow. · First year applicants must be participating in a group-rating O 20percentduringthefirstyearintheprogram; O 15percentinthesecondyear; programattheOCPapplicationdeadline.Inaddition,BWCwill O 10percentinthethirdyear; notrenewtheemployerforgroupratingfortheupcomingrating O 5percentinthefourthyear; yearbeginningJuly1forprivateemployersorJan.1forpublic O 5percentinthefifthyear. employers. · The OCP is a voluntary program that an employer may · The employer cannot have more than one significant claim participateinforthedurationasignificantclaimremainsinhis andthreenon-significant,medical-onlyclaimsintheupcoming orherexperience.BWCwillalsore-evaluatetheemployereach experienceperiod. yeartodetermineeligibility.BWCwillhavethefinalauthorityto approveanemployer'sparticipationinOCP. · The employer cannot have cumulative lapses in workers' compensationcoverageinexcessof40dayswithinninemonths · BWCdefinesasignificantclaimasaclaimwhosetotalvalueor maximumclaimvalue,whicheverislower,willbegreaterthan attheapplicationdeadline.Theemployeralsomustbecurrent theemployer'stotallimitedlosses(TLL).Oncedesignatedasthe onallbalancesowedtoBWCbytheapplicationdeadline. significantclaim,BWCcannotchangeittoanotherclaimafter theemployer'sinitialenrollmentintheprogram. · An employer who meets all the eligibility requirements and makes application will receive the following discount off the · Thetotalcostsofthethreenon-significant,medical-onlyclaims cannotexceedtheemployer'sTLL. baserate: IhavefullyreadandunderstandtheOCP'srules.IunderstandBWCwillrevokethediscountatthebeginningofthenextpolicyyearifI havemorethanonesignificantandthreemedical-onlyclaims,orifthecombinedclaimcostsofthethreemedical-onlyclaimssurpasses theTLL,orifIfailtomeetanyoftherequirementsofparagraph(C)orparagraph(D)ofOhioAdministrativeCode(OAC)4123-17-71.This includesthatImustcompleteahalf-day,classroomstyleclassofferedbyBWC'sDivisionofSafety&Hygienethefirstyearofparticipationandthreehoursonlinetrainingthroughwww.bwc.ohio.govinsubsequentyears.Bysigningthisapplication,IcertifyIhaveread andunderstandtheprogramrequirementsoutlinedinOAC4123-17-71,andIcertifyIwillcomplywithalloftheprogram'srequirements. Owner/partner; officer name Signature Title Date signed X EmployersshouldrefertoOAC4123-17-74AppendixCtodeterminewhichprogramsarecompatibleasnotallprogramsarediscount compatible. BWC-4842 (Rev. 9/29/2014) OCP-1 American LegalNet, Inc. www.FormsWorkFlow.com