Self - Insured Professional Employer Organization (PEO) Client Relationship Notification BWC - 8003 ( May 21 , 2019 ) UA - 3 SI Instructions Use this form to notify BWC of a new client or a termination of a client. Self - Insured PEO: Email form to SIINQ@bwc.state.oh.us. Notice: BWC must receive new contract a nd termination notifications within 30 days of the effective date of the contract or termination. Pursuant to Ohio Administrative Code 4123 - 17 - 15.1, if you do not notify BWC within the required time frame, BWC will recognize the date it receives the UA - 3 a s the effective date. For each occurrence that BWC is not notified timely, a late fee will be assessed. BWC will not process the UA - 3 unless all informati on is completed and accurate, including a state - fund policy application number and/or an active client policy number. PEO i nformation Company name Policy number Contact person name Telephone n umber PEO lease information Check only one New lease (All under the PEO policy) New lease (All under the c lient policy) Lease termination Effective date of new lease or termination in Ohio Change in lease type moving from all under PEO to all under c lient, or moving from all under c lient to all under PEO Client company information Client company n ame Client p olicy n umber DBA Federal ID n umber Mailing a ddress (P.O. Box if applicable) Client phone n umber City State Nin e - digit ZIP c ode Signatures are required by both parties Title Date Print client signatory Client signature Print PEO signatory PEO signature Note: Signing this form is an acknowledgement that all the information is complete and true to the best of your knowledge. Omission of any of the items required or intentional mis representation of any of the above information on this form may lead to registration revocation as outlined in Ohio Revised Code Section 4125. American LegalNet, Inc. www.FormsWorkFlow.com