Notification of Policy Update Have questions? Need assistance? BWC is here to help! Call 1-800-644-6292, 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 www.bwc.ohio.gov. Purpose of form: To notify BWC of changes to the information on your Ohio workers' compensation policy. Complete all sections of this form that apply to your updates. The sections are: Section A - Update business information (legal business name, trade name (DBA), entity type and/or owners/officers); Section B - Update address and contact information; Section C - Request to cancel elective coverage; Section D - Request to cancel Ohio workers' compensation coverage; Section E - Request to cancel Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio (U-131). Your assigned workers' compensation policy number and responsibility for premium will not change as a result of completing the Notification of Policy Update (U-117). BWC will not issue a new policy number in situations where essentially the same employer, regardless of entity type, has an existing BWC policy (i.e., only one policy is established for any given individual, group of individuals or legal entity). Coverage for certain owners or ministers is voluntary. Listed below are the categories of individuals that qualify for elective coverage. If you wish to elect coverage on a qualifying individual, you must complete and submit an Application for Elective Coverage (U3-S), which is available at www.bwc.ohio.gov or by calling 1-800-644-6292. · Sole proprietor · Partnership · Limited liability company acting as a sole proprietor · Limited liability company acting as a partnership · Family farm corporate officers · Ordained or associate minister of a religious organization · Individual incorporated as a corporation (with no employees) This form is not intended for situations where the employer succeeds, in whole or in part, another employer in the operation of a business. Complete Application for Ohio Workers' Compensation coverage (U-3) if you are a new/successor employer. Notify BWC by following these steps. 1 Complete all sections of the form that apply to your policy updates. 2 Sign and date the application. BWC cannot process this form without a signature. 3 Mail the completed form to: Ohio Bureau of Workers' Compensation Policy Processing, 22nd floor 30 W. Spring St. Columbus, Ohio 43215-2256 Policy Processing 614-719-5313 4 Fax completed form to: BWC-7623 (Rev. Aug. 18, 2016) U-117 American LegalNet, Inc. www.FormsWorkFlow.com Provide your policy number, federal identification number or Social Security number and legal business name as it exists on your current policy. Provide your updated information in the appropriate section of this form. Previous federal employer identification number or Social Security number Previous legal business name Policy number Section A New/update business information You can request an update to the legal business name, trade name or doing business as (DBA), federal employer identification/Social Security number, entity type and/or owners/officers on a workers' compensation policy when the employer is essentially the same employer (same or similar ownership group). Update business name and/or federal employer identification number or Social Security number New legal business name New trade name or DBA New federal employer identification number or Social Security number Effective date Update business entity type Please check the one business entity type below that applies to you and attach supporting documentation (e.g., certificate from Secretary of State and related materials, legal contract, etc.). Sole proprietor Partnership Limited partnership Incorporation date Limited liability company acting as a sole proprietor Limited liability company acting as a partnership Limited liability company acting as a corporation Charter number Corporation Individual incorporated as a corporation Family farm corporation State where incorporated Have you changed the nature of your business operation or finished products? Explain Yes No Provide the reason for change in legal business name. Corporate name change Same/similar ownership group changing legal entity type Other Please explain: U-117 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Policy number Section A Update business information (continued) Update owner/officer information Name #1 (last, first, middle) Home address (street or PO Box) City Social Security number Name #2 (last, first, middle) Home address (street or PO Box) City Social Security number Name #3 (last, first, middle) Home address (street or PO Box) City Social Security number State Title Phone ZIP code State Title Phone Effective date % Ownership ZIP code State Title Phone Effective date % Ownership ZIP code Effective date % Ownership List names of owner(s) and/or officer(s) no longer affiliated with the business (print name). Name End date Section B Update address and contact information Update primary physical location and contact information BWC uses the primary address to assign one customer service office for all your risk-management services. Please provide the address for your primary Ohio location best capable of handling and resolving your riskmanagement issues or an out of state location if you have no physical Ohio location. Street (Do not use P.O. box) State, ZIP code Location fax Contact name City Location phone E-mail address Contact phone Update mailing address (if different from primary physical location) Street State, ZIP code Mailing address fax number Contact name City Mailing address phone number E-mail address Contact phone U-117 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Section C Request to cancel elective coverage Name Policy number If elective coverage is no longer required for one or more qualifying individuals, cancel elective coverage for the individual listed below. Effective date of cancellation Upon cancellation of elective coverage, BWC will NOT pay benefits for work-related injuries. You must report and pay elective coverage wages up through the end date of the elective coverage. If you choose to elect coverage for a qualifying individual in the future, you must complete and submit a U-3S. You can obtain this application by