Application For Retrospective Rating Plan For Public Employers
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Application For Retrospective Rating Plan For Public Employers Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Application For Retrospective Rating Plan For Public Employers, BWC-7524, Ohio Workers Comp, Employers
Application for
Retrospective-Rating Plan
for Public Employers
BWC will reject
incomplete applications.
Instructions
E-mail address
Federal ID number
Policy number
Employer name
Address
City
State
ZIP code
Contact name
Telephone 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.
Maximum premium
150 percent
200 percent
(Claim limit) (maximum costs chargeable to a single claim)
$200,000
$300,000
$400,000
No claim limit
If you do not meet the requirements for Tier I, do you wish BWC to consider you for the Tier II plan?
Yes
No
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
premium of 150 percent.
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 public employer taxing district policy year is Jan. 1 to Dec. 31.
You must use NCCI manual classification numbers for BWC to
consider your application.
Payroll rounded to the nearest $1,000
NCCI
manual number
Payroll
NCCI
manual number
NCCI
manual number
Payroll
Payroll
Owner/partner/officer statement of agreement: I have read the retrospective-rating rules in their entirety. I understand the rules and
agree to comply with the terms of the retrospective rating plan.
Owner/partner/officer name (type or print)
Title
Signature
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.
For the policy year effective
BWC-7524 (Rev. 11/16/2010)
U-21
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