PDP+ Plan of Action Please fax this completed form to BWC at (614) 365-4976. For private employers the POA must be received by BWC no later than March 31 for program years that start July 1, and no later than Sept. 30 for program years that start Jan. 1. For public employer taxing districts the POA must be received by BWC no later than Sept. 30, except for public school districts, which are due by Nov. 15. Employers will lose the premium discount for the entire year for non-receipt of the POA demonstrating your 10-Step implementation. Policy number PDP+ Program Period Employer DBA Telephone number ( ) Street address E-mail address City State Employer printed name Title Employer signature Date ZIP code Briefly describe the product or service your business provides. How many full and part-time employees do you have in Ohio? (If seasonal, please indicate vs. non-seasonal) Full-time Seasonal Non-seasonal Part-time Seasonal Non-seasonal Temporary Seasonal Non-seasonal Leased employees Seasonal Non-seasonal BWC-8006 PC (Rev. 10/5/07) UA-6 American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com