Application for Optional Supplemental Coverage Have questions? Need assistance? We’re here to help! Call 1-800-OHIOBWC, and follow the prompts to reach a customer service representative. You can dial the number nationwide, and in Canada and Mexico from 7:30 a.m. to 5:30 p.m. EST. Remember, you can access information and request services by visiting BWC’s Web site at ohiobwc.com All employers with one or more employees must carry workers’ compensation coverage. It’s the law. However, Ohio law makes coverage optional for owners or ministers in one of the the following categories: Sole proprietor, Partnership, Limited liability company acting as a sole proprietor, Limited liability company acting as a partnership, family farm corporate officers, individual incorporated as a corporation, and ordained or associate ministers of a religious organization. These individuals may cover themselves by submitting this form. Supplemental coverage is effective the date BWC receives the application. You must complete an additional application for optional supplemental coverage to cover owners or ministers you wish to add at a later date. Remember, if you choose not to cover yourself and you are injured at work, BWC will not provide coverage, and other insurance may not cover your work-related disability or medical bills. Contact your insurance carrier if you have questions. STOP! If you do not have an existing policy with BWC, please complete the Application for Ohio Workers’ Compensation Coverage (U-3) instead of this form. Payroll reporting requirements Sole proprietors and partners (including limited liability companies acting as a sole proprietor or partnership): For all individuals with supplemental coverage, you must report a minimum of $100 weekly per person even if actual income is less; $2,600 semiannually up to a maximum of $800 of payroll per week per person; $20,800 semiannually; or an aggregate of $41,600 annually. Individuals who earn between the minimum and maximum will report their actual net incomes based on their federal tax forms, Schedule C for sole proprietors, or Schedule K-1 for partnerships, inclusive of any draws taken. Officers of a family farm corporation: These individuals are exempt from workers’ compensation coverage. However, you are required to cover your employees. To qualify as a family farm corporation the following criteria must be met: • The family farm must be founded for the purpose of farming animal or plant products intended for consumption by human beings or animals (excluding nurseries and flower production enterprises); • A majority of the shareholders must be related within the fourth degree of kinship (siblings, parents, grandparents, aunts, uncles, great aunts, great uncles or first cousins) or be the spouse of such persons; • No shareholder may be a corporation; • At least one of the related persons within the corporation must reside on or actively operate the farm. Corporate officers of a family farm electing supplemental coverage for themselves agree to report a minimum of $100 of payroll per week per person; $2,600 semiannually up to a maximum of $800 of payroll per week per person; $20,800 semiannually; or an aggregate of $41,600 annually. Individuals who earn between the minimum and maximum will report their actual wages based on their federal tax forms, W-2 for corporations or S corporations. Officers must report a reasonable wage for services they perform including W-2 wages. This may include all or part of the ordinary income (K-1). Religious organizations: Ohio law requires religious organizations to cover their paid employees. However, ordained ministers and associate ministers are not considered employees for the purpose of workers’ compensation. For all ministers with supplemental coverage, you are required to report their actual wages paid (no minimum or maximum applies). Individual incorporated as a corporation: To qualify under this type you must have a single/sole owner with no employees. Corporations having more than one owner or a single/sole owner with employees are by law required to have workers’ compensation coverage for all personnel associated with the corporation, including all corporate officers. Individual corporate officers electing supplemental coverage for themselves agree to report a minimum of $100 of payroll per week even if actual income is less; $2,600 semiannually up to a maximum of $800 of payroll per week; $20,800 semiannually; or an aggregate of $41,600 annually. Individuals who earn between the minimum and maximum will report their actual wages based on their federal tax forms, W-2 for corporations or S corporations. Officers must report a reasonable wage for services they perform including W-2 wages. This may include all or part of the ordinary income (K-1). Supplemental coverage type Sole proprietor Partnership Family farm corporate officers Limited liability company acting as a sole proprietor Ordained or associate minister of a religious organization Legal business name Limited liability company acting as a partnership Individual incorporated as a corporation Policy number Trade name or doing business as name Federal employer identification number or Social Security number Mailing address City Street E-mail address State ZIP code Telephone number BWC-7613 (combines U-43, U-136 and C-116) U-3S Rev.10/05/2004 American LegalNet, Inc. www.USCourtForms.com Owners’/Ministers’ information – list owners/ministers electing supplemental coverage (See reverse for additional coverage.). Name #1 Social Security number Residential address City Name #2 Title State ZIP code Social Security number Residential address City Name #3 Title State ZIP code Social Security number Residential address City Residential address State City Name #5 ZIP code State City ZIP code ZIP code Social Security number Residential address City Residential address State City Name #8 ZIP code State City Duties Title ZIP code Social Security number Residential address Duties Title Social Security number Name #7 Duties Title State Name #6 Duties Title Social Security number Residential address Duties Title Social Security number Name #4 Duties Duties Title State ZIP code Duties Certification – signature required By my signature, I certify that I have the authority to execute this application, and that the facts set forth on this application are true and correct to the best of my knowledge and belief. I am aware that any person who does not secure or maintain workers’ compensation coverage and pay all appropriate premiums in accordance with Ohio laws or misrepresents, conceals facts, or makes false statements to obtain coverage may be subject to civil, criminal and/or administrative penalties. Print name Signature and title Date WARNING: No insurance is in effect until BWC receives the completed application. Mail completed form to: Ohio Bureau of Workers’ Compensation Policy Processing Department, 22nd Floor 30 W. Spring St. Columbus, OH 43215-2256 Apply for or cancel supplemental coverage online at: ohiobwc.com BWC use only Policy number Effective date Date received Initials Manual class number(s) American LegalNet, Inc. www.USCourtForms.com