Application for Renewal of Authorization to Operate as a Self-insured Risk (as outlined in Ohio Revised Code Section 4123) Self-Insured risk number Renewal date Instructions • Please answer all questions. If not applicable, use symbol N/A. • You must file all requests for data and financial statements, or BWC will return the application as incomplete. • Mail this form to: ATTN: Self-Insured Department, Ohio Bureau of Workers' Compensation    0 W. Spring St., 26th Floor, Columbus, Ohio 43215-2256 3 Company Information Employer name (shown exactly as it is in the Articles of Incorporation) Federal I.D. number Address Number of Ohio employees as of application date City State County Nine-digit ZIP Code Corporate phone number Type of entity (check appropriate box) Corporation Association Corporate FAX number ( Corporate contact person ( ) Date of incorporation ) State of incorporation Partnership Sole proprietor Complete This Section If Applicable Name of ultimate USA parent (show exactly as it is in the Articles of Incorporation) State of incorporation Date of incorporation Ultimate USA parent Federal I.D. number Percentage of ownership % Please attach a detailed organizational chart, if applicable. Subsidiary Information Please list subsidiary corporation(s) in Ohio, authorized by the Bureau to operate under this self-insured risk number. Authorized subsidiaries are listed on the Certificate of Employer's Right to Pay Compensation Directly. If an entity does not appear on your certificate, you must file an initial application for self-insurance with the self-insured department. Organization name Incorporation date State in which incorporated Employer federal I.D. number BWC-7207 (Rev. 7/28/2008) SI-7 American LegalNet, Inc. www.FormsWorkflow.com Excess Workers' Compensation Insurance Does your company carry excess workers' compensation insurance? Yes No Name of carrier: Name of agent: Telephone number: ( ) Policy number: Representative Information Name of person or organization to whom renewal correspondence should be directed per AC-2 form Telephone number ( ) Telephone number Name of attorney or service representative, if any ( ) Corporate Restructuring Has your corporate name, structure or address been revised during the past year? Yes No Merger Asset purchase Name revision Other Explain: Please note: For BWC to properly process the above referenced revisions, please provide secretary of state papers and board of director documents to the above listed address. For requested financial information please see the attached Important Update Request Ohio assets $ Calendar and/or fiscal year ending Ohio gross payroll $ Certification (Notary seal) (Corporate seal) State of ____________________ County of _______________________ ss_____________________________ being duly sworn says that he/she is the ___________________________ of _______________________ , the employer referred to in the foregoing is true to the best of their knowledge. Sworn to before me, this _____ day of _________________ , 19 _____ Notary signature Corporate officer signature American LegalNet, Inc. www.FormsWorkflow.com Instructions • 1. If you find no discrepancies please indicate this and return this form with your packet. • 2. Indicate all locations where you maintain claims records for auditing purposes. • 3. Indicate all claims locations, which have been closed or sold, and the effective dates. In addition, please designate the Ohio location that will administer the claims. • 4. You must use the division codes assigned to your various locations when filing claims. Information Update Request Self-insured Risk No. Company: This form completed by Telephone number Name and title ( ) Company: DBA/Division: Attention: Telephone number: Address: Claim files maintained Check if there are no changes Yes No Yes No Yes No Company: DBA/Division: Attention: Telephone number: Address: Claim files maintained Check if there are no changes Company: DBA/Division: Attention: Telephone number: Address: Claim files maintained Check if there are no changes Additional locations on reverse side BWC-7207 (Rev. 7/28/2008) (SI-220 comb. within) SI-7 Pg. 2 American LegalNet, Inc. www.FormsWorkflow.com IMPORTANT NOTICE: When filing claims, use the division codes assigned to your various locations. Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Yes No Yes No Yes No Yes No Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained American LegalNet, Inc. www.FormsWorkflow.com