Ohio Bureau of Workers' Compensation Application for Choose one of the program dates below. Instructions • Complete the application. • An officer, partner, or owner (sole proprietor) must sign the application. • Please type or print clearly. • Fax completed application to (614) 365-4976 by the deadline below. Beginning Jan. 1, 20__­____ (Jan. 1 - Dec. 31) Beginning July 1, 20­__­____ (July 1 - June 30) Please obtain and retain proof of successful transmission. Employer name Policy number Trade name /DBA Fax ( ) Street address (Please list additional locations in Ohio on reverse side.) State ( ) Federal I.D. number E-mail address City Office telephone number Safety plan coordinator Nine-digit ZIP code Alternate safety plan coordinator County Number of employees in Ohio Full time Part time • This application is intended for first-time applicants, employers having a one-year absence from the program who want to reactivate participation and employers reapplying for the two year extension. • Employers participating effective July 1 must submit a Plan of Action and Self-Assessment with appropriate supporting documentation by March 31 to BWC. Employers participating effective Jan. 1, must submit a Plan of Action and SelfAssessment with appropriate supporting documentation by Sept. 30, except for public school districts, which are due by Nov. 15. Failure to complete a Plan of Action and SelfAssessment by the indicated deadline will result in retroactive loss of the discount to the beginning of the policy year. • Employers in the first year must complete and pass steps 1, 2, 6 and any two of the remaining seven steps. Participants also must attend any of BWC’s pre-approved Division of Safety & Hygiene’s courses, Workers’ Comp University, The Ohio Safety Congress & Expo, or public or private courses pre-approved by BWC to satisfy the Step 6 requirement. Employers in the remaining years must complete and pass all 10 steps of the 10-Step Business Plan including attendance at an approved Step 6 class. I understand BWC will revoke the discount to the beginning of the policy year if we do not submit a Plan of Action and Self-Assessment. I understand that continued participation in the Premium Discount Program Plus is contingent on the successful implementation of BWC's 10-Step Business Plan. Officer name Signature Officer title Date Certified sponsor (if applicable) Certified sponsor association name BWC USE ONLY Effective date  Initials  BWC-8005 (Rev. 1/16/2008) UA-5 American LegalNet, Inc. www.FormsWorkflow.com ATTENTION EMPLOYER PROGRAMS UNIT L-22 BUREAU OF WORKERS COMPENSATION 30 W SPRING ST COLUMBUS OH 43215-2256 FOLD HERE. DO NOT STAPLE USE TAPE, GLUE OR TAB TO SEAL ➔ ➔ s432152256307s Contact person Telephone number FOLD INSIDE ONLY General or district manager Address City Contact person State Telephone number Nine-digit ZIP Code County General or district manager Address City Contact person State Telephone number Nine-digit ZIP Code County General or district manager Address City State Nine-digit ZIP Code County American LegalNet, Inc. www.FormsWorkflow.com ➔ • To better service your account, please attachlocations. additional sheets as needed listing all Ohio ➔ FOLD HERE FIRST ➔ ➔ FAX completed application to (614) 365-4976. Please obtain and retain proof of successful transmission.