Public Employer Agreement for 100-percent EM Cap Application deadline is the last business day in March Instructions Please type or print clearly. An officer, partner or owner must sign this agreement. Send a completed agreement via fax to 614-365-4976. You may also mail this agreement to: BWC, 30 W. Spring St., 22nd Floor, Columbus, OH 43215. Please retain a copy for your records and proof of successful fax transmission. Application deadline is the last business day in March. Legal business name Primary physical location Phone Fax City Email State BWC policy number ZIP code We will cap or limit the Jan. 1, 2012, experience modification (EM)% at a 100-percent increase from the published Jan. 1, 2011, EM percent. We will not adjust the Jan. 1, 2011, published EM percent for the purposes of determining the cap for the Jan. 1, 2012, rating year. We will not apply a cap to any EM-percent decreases. Employer requirement To be eligible for the cap in the first policy year, an employer must complete steps one, two, six and any other two steps of the 10-Step Business Plan for Safety of rule 4123-17-70 of the Ohio Administrative Code (OAC). The employer shall submit the required documentation by the last day in September. To effectively control your workers' compensation costs, you must use the latest claim-management techniques. For assistance with implementing the 10-Step Business Plan for Safety and other claims-management techniques, contact your local customer service office or a BWC-certified, 10-Step Business Plan for Safety sponsor. Eligibility for participation The employer shall be current as of Dec. 1 immediately prior to the policy year to which we will apply the cap (not more than 45 days past due) on any and all premiums, assessments, penalties or monies otherwise due to any fund administered by us, including amounts due for retrospective rating. The employer cannot have cumulative lapses in workers' compensation coverage in excess of 40 days within the 12 months preceding Dec. 1 immediately prior to the policy year to which we will apply the cap. We will only apply the cap to a policy that has an initial published Jan. 1, 2012, EM of 1.01 or greater. Any subsequent adjustments to the initial published EM will not affect the employer's cap eligibility, including an employer that does not initially qualify for the cap. Please note To be eligible for the cap in the second year, an employer must complete the remaining steps of the 10-Step Business Plan for Safety of rule 4123-17-70 of the OAC. If you fail to comply with these requirements, BWC will remove the cap for the policy year in which the requirements were not met. I have read and understand the rules of the 100-percent EM Cap. I understand BWC will remove the cap from the policy year beginning Jan. 1, 2012, if I do not complete the required steps of the 10-Step Business Plan for Safety. Steps one, two, six and two additional steps must be completed in the first policy year, per rule 4123-17-70 of the Ohio BWC Administrative Code. Completed documentation is due by the last day in September. Please indicate who you will work with to ensure compliance with the requirements to receive the 100-percent EM Cap. BWC representative BWC-certified, 10-Step Business Plan for Safety sponsor. Name: Note: A list of BWC-certified, 10-Step Business Plan for Safety sponsors are available on our Web site, www.bwc.ohio.gov. I do not wish to participate in the 100-percent EM Cap for the policy year beginning Jan. 1, 2012. Officer Officer signature Title Date BWC-7522 (12/15/2011) PC U-19 American LegalNet, Inc. www.FormsWorkFlow.com