BWC will reject incomplete applications Instructions Application for Retrospective-Rating Plan for Private Employers · Anowner/partner/officermustsigntheapplication. · Youmustfileanewapplicationforeachpolicyyear. · OnceBWCapprovestheapplication,theplanwillremaininforcefortheentirepolicyyear. · EmployersmustfiletheapplicationandallotherrequireddocumentationbythelastbusinessdayofJanuaryforthepolicyyearbeginningJuly1. · BWC charges an annual minimum premium based on a factor of the estimated policy year experience-rated/base-rated premium even if there are no losses. · BWCoffersTierIandTierIIplans.TierIisavailabletoemployersmeetingallBWCrequirements,includingfinancialstrength.TierIIisavailableto employerswhodonotmeetTierIrequirements,butdomeetotherrequirementsasspecifiedbyBWC.Applicantsmustsubmitauditedfinancialstatements(accordingtoGAAPstandards)forthelastfiveyears,whichincludesabalancesheet,incomestatementandaretainedearningsstatement. · Applicationforanyretrospective-ratingplanisoptional;butifapplicationismade,alloperationsoftheemploymententityaresubjecttoretrospectiverating. · Directquestionsconcerningthisapplicationtotheemployerprograms'retrospective-ratingunitat614-466-6773. · Youmaysubmitacompletedapplicationinoneofthreeways: Online­www.bwc.ohio.gov; Fax ­614-621-1405; Mail­BWC,EmployerPrograms,Retrospective-RatingUnit,22ndFloor,30W.SpringSt.,Columbus,OH43215-2256. While participating in the Retrospective-Rating Program, you should verify other BWC programs that are compatible with it. You may participate in morethanoneBWCprogram.However,onlycertainprogramsmaybecombinedinthediscountcalculation.Pleasereferencethecompatibilitychart foundinOhioAdministrativeCode4123-17-74. Federal ID number Employer name Address City Contact name Contact title State ZIP code Telephone number Email address Policy number ( ( ) ) Fax number Retrospective rating plan parameter selections: The employer must select the retrospective-rating plan parameters listed below. BWC will determine the minimum and maximum premium level, as well as the exposure to claim losses by the selections made. Tier I parameters To enroll in the Tier I plan, choose one of the claim limits and one maximum premium percentage below. (Claim limit) (maximum costs chargeable to a single claim) $100,000 $200,000 $300,000 $400,000 No claim limit Tier II parameters To enroll in the Tier II plan, choose one of the claim limits below. (Claim Limit) (maximum costs chargeable to a single claim) $100,000 $125,000 The Tier II plan, only offers a maximum premiumof150percent. Maximum premium 150percent No 200percent If you do not meet the requirements for Tier I, do you wish BWC to consider you for the Tier II plan? Yes Financial statements are attached for consideration. Estimated policy year payroll You must provide the estimated payroll you will report during the policy year for each manual classification assigned to your policy number (attach additional pages as needed). The private employer policy year is July 1 to June 30. The payroll information below will be used to set the estimated annual premium for the policy year beginning July 1. You must use NCCI manual classification numbers for BWC to consider your application. Note: If you have more than 15 NCCI manual numbers, please attach a second page. NCCI manual number Payroll Payroll rounded to the nearest $1,000 NCCI manual number Payroll NCCI manual number Payroll Retrospective-Rating Application ­ Statement of agreement: I have been authorized to sign and execute this application for the retrospective-rating plan on behalf of the company. I have read and understand the retrospective-rating plan rules in their entirety and agree to comply with the terms of the retrospective-rating plan, including payment of the annual claims billings in accordance with the plan and the governing rules. Owner/partner/officer name (type or print) Signature Title Date Note: BWC's employer programs' retrospective-rating unit must review and approve this application before it becomes effective. BWC will provide written notification of application acceptance/rejection and applicable minimum premium percentage following the review. BWC-7523 (Rev. April 1, 2016) For the policy year effective American LegalNet, Inc. www.FormsWorkFlow.com U-20