Application for Representative Identification Number (RIN) Fax this completed form to BWC at 614-621-3437. After receiving a RIN number an employer or injured worker may assign you as a representative to an individual claim using the Employer Authorized Representative (R-1) or Injured Worker Authorized Representative (R-2). Applicant's name The listed name must match the name reported to the Social Security Administration or, if using an employer identification number, the associated name reported to the Internal Revenue Service. Complete the appropriate option below. You must complete one of the three options. Individual attorney applying for RIN Name Option 1 Option 2 Ohio attorney registration number; or Certificate of Pro Hac Vice registration number If you are an out-of-state attorney, you must attach a Certificate of Pro Hac Vice to this application. Individual non-attorney applying for RIN Name Check if you are: Union representative Other (Identify) Option 3 Company, firm or union applying for RIN; individual employees/attorneys may share one RIN. Name Contact name Check if you are: Law firm Local union Third-party administrator Other (Identify) Taxpayer identification number (Social Security (SSN) or employer identification number (EIN) If you anticipate payment for services, you must also attach a W-9 to this application. Taxpayer identification number (SSN or EIN) Applicant contact information Street address City Email address Phone number Signature of applicant (if applying as company or firm, signature of contact person) BWC use only Representative number issued Signature of assigning BWC employee Fax number Date State ZIP code Date Date BWC-6104 (July 20, 2016) R-4 American LegalNet, Inc. www.FormsWorkFlow.com