Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio Please read this information before completing the form. This information concerns only employees who work outside of Ohio on a temporary basis. Ohio law allows employers to obtain coverage in other states in addition to their Ohio coverage. (Ohio Revised Code (ORC) 4123.292) · Ohio coverage applies to work performed temporarily in another state if the claim is filed with BWC. · However, the employer may elect to obtain workers` compensation coverage from an authorized insurer in the state which he or she performs work. (NOTE: Depending upon the law of the other state, it may require the employer to obtain coverage in that state.) This other state`s coverage applies to only work done outside of Ohio. · This selection allows the employer to segregate payroll reported to the other states insurer for work done outside Ohio from their Ohio payroll reported to BWC. · Mail both documents to: BWC Policy Processing Department, 30 W. Spring St., 22nd Floor, Columbus, OH 43215. Payroll reporting and premium payment requirements Employers electing coverage from another state: · Must report payroll and pay premium to BWC for all work their employees do in Ohio; · Should NOT include work done outside of Ohio when reporting payroll or calculating premium payments to BWC; · Must report payroll for work done outside of Ohio to BWC on a separate form. (This is for record-keeping purposes only since they do NOT have to pay an Ohio premium for out-of-state work.); · Must both report and pay premium for any work done outside of Ohio to the other state or insurance company providing the coverage. How to meet the notification requirement Employer's notification to BWC Employers electing coverage from another state must: (1) notify BWC in writing; (2) give BWC the name of the state agency or insurance company providing the coverage. · Complete this form and return it to BWC to meet these requirements. · Include a copy of the insurance policy as proof of coverage from the other state. This certifies that the employer listed below has elected coverage from an insurer other than BWC for work done outside of Ohio. The employer is submitting this form along with a copy of his or her insurance policy from the other state where work occurs. This shows proof of workers' comp coverage from an authorized insurer. The employer will immediately notify BWC in writing of cancellation of this policy for any reason. Employer information Employer name Street address City and state Zip code BWC policy number Phone number Fax number E-mail address Other-states' insurance information Insurer name Street address City and state Insurer name Street address City and state Other-state's insurance policy number Effective date of policy Zip code Other-state's insurance policy number Effective date of policy Zip code Certification I certify this employer has elected to obtain workers' comp coverage from an authorized insurer other than BWC for work done outside of Ohio. I also certify I have the authority to notify BWC of this election. My signature indicates the statements on this form are true to the best of my knowledge. I am aware that anyone who makes false statements, conceals facts or misrepresents payroll to BWC may be subject to civil, criminal and administrative penalties. Signature of owner, partner, member, or executive officer Title Printed name of above signature Telephone number Date E-mail address BWC-7637 U-131 American LegalNet, Inc. www.FormsWorkFlow.com