Notification of Business Acquisition/Merger or Purchase/Sale Have questions? Need assistance? BWC is here to help! Call 1-800-OHIOBWC, and listen to the options to reach a customer service representative. You can dial the number nationwide, and in Canada and Mexico from 7:30 a.m. to 5:30 p.m. EST. Remember, you can access information and request services by visiting BWC's Web site at ohiobwc.com Use this form to notify BWC when succeeding, in whole or in part, another in the operation of a business. If you are the successor/new employer and do not have Ohio workers' compensation coverage, you must complete an Application for Ohio Workers' Compensation Coverage (U-3). If you have Ohio workers' compensation coverage, you only need to submit the U-118. Ohio workers' compensation rule (Rule 4123-17-02 Basic or manual rate) requires an employer that succeeds another employer in the operation of a business, in whole or in part, to notify BWC of the succession. Additionally, the succeeding employer must preserve the former employer's payroll records for the ive years preceding the date of succession. Whenever one employer succeeds another employer in the operation of a business, in whole or in part, BWC requires information on the succession to calculate the experience rating of the succeeding employer. Additionally for successions taking place on or after Sept. 1, 2006, where one employer wholly succeeds in the operation of a business, BWC shall transfer to the successor any and all existing and future liabilities or credits of the former employer in addition to the experience transfer. If an employer purchases or acquires only a portion of the business, BWC transfers only that portion of the former employer's experience to the succeeding employer. BWC will inspect the former employer's payroll and claims records to determine what should transfer to the successor for rate calculation purposes. Notify BWC by following these steps: 1 Complete all sections of this form and provide as many details as possible to avoid unnecessary requests for additional information; 2 Sign and date the form; 3 Mail the completed form to: Ohio Bureau of Workers' Compensation OR Policy Processing, 22nd floor 30 W. Spring St. Columbus, Ohio 43215-2256 4 Fax completed form to: Policy processing 614-719-5313. Section A - General information Provide general information for the succeeding new employer and former employer. If you are the successor/new employer and do not have Ohio workers' compensation coverage, you must complete the U-3 application. You can obtain the U-3 application by visiting BWC's Web site at ohiobwc.com or by calling 1-800-OHIOBWC. You can submit the U-3 application online at ohiobwc.com. Section B - Transaction detail to be completed by the former employer BWC uses the information provided in this section to determine if a succession has occurred. BWC evaluates criteria, including but not limited to, criteria listed below to make this determination. · Business ownership · Continuity of business operations · Real estate, plant and equipment, material inventories and other real property · Customer proiles · Industrial pursuit · Employee roster Section C - Transaction detail to be completed by the new/successor employer BWC uses the information provided in this section to determine if a succession has occurred. BWC evaluates criteria, including but not limited to, criteria listed below to make this determination. · Business ownership · Continuity of business operations · Real estate, plant and equipment, material inventories and other real property · Customer proiles · Industrial pursuit · Employee roster Section D - Certiication This section is where the parties associated with the transaction read the certiication statement and provide their signatures. BWC has the authority to proceed with processing the transaction without the signature or agreement of one or both of the parties. BWC-7624 Rev. 10/28/2010 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com U-118 Section A - General information If you do not have Ohio workers' compensation coverage, you must complete and submit the U-3 application. You can obtain the U-3 application at ohiobwc.com or by calling 1-800-OHIOBWC. Succeeding employer - complete section A, C and D only Legal business name Ohio workers' compensation policy number Telephone number Trade name or doing business as name (DBA) Former employer - complete section A, B and D only Legal business name Trade name or doing business as name (DBA) Ohio workers compensation policy number Telephone number Section B - Transaction detail to be completed by the former employer 1. 2. 3. 4. On what date did you sell the business? If you are no longer operating in Ohio, what was the date you last employed Ohio employees? Did you sell all or part of your business? If this is a partial acquisition or sale, of an existing business, explain what portion or location of the entire operation was sold. Is there a purchase/sale agreement associated with this transaction? sale agreement.) Yes No (BWC may request a copy of the purchase/ 5. Do you continue to operate any additional Ohio locations under this policy? Explain: Yes No 6. Provide the names of all partners, corporate oficers or individuals that have ownership interest for the former and succeeding employer. Ownership interests for former employer Ownership interests for succeeding employer 7. Has the business been in continuous operation? Explain: Yes No 8. Is the succeeding employer continuing to operate in the same location? Explain: Yes No 9. How many employees did you have prior to the sale? ________________________ U-118 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Policy number Section B - Transaction detail to be completed by the former employer (continued) 10. Did you sell any machinery or equipment to the successor? Explain: Yes No 11. Did you sell any contracts or customers? Explain: Yes No 12. Provide any additional information you believe pertinent to this transaction. (Attach additional information as needed) Section C - Transaction detail to be completed by the new/successor employer 1. 2. 3. 4. What date did you acquire/purchase the business? From whom did you acquire/purchase the business? Is there a purchase/sale agreement associated with this transaction? (If yes, BWC may request a copy of this agreement.) Yes No Provide the names of all partners, corporate oficers or individuals that have an ownership inte