Request for retroactive coverage and penalty abatement and/or a one-time forgiveness Employers or their authorized representatives must submit a written request for retroactive coverage and penalty abatement and/or a governor's executive order one-time forgiveness. Use this form to make the request. You must complete each section in full for BWC to consider your request. Fax the completed form to 614-719-5313. Company name Contact person Contact email Policy number Phone ( ) Fax ( - ) I. Retroactive coverage and penalty abatement Ohio Administrative Code (OAC) rule 4123-14-03 allows BWC's administrator to approve retroactive coverage and penalty abatement if an employer can show good cause for late payment and/or late reporting. The employer's lapse duration must be 59 days or less for the administrator to grant retroactive coverage. OAC 4123-14-06 states the employer must file the protest of BWC's decision on the request, protest, petition or application within two years of receipt of BWC's determination. Yes No I request retroactive coverage and penalty abatement for the lapse date of: / / . In order for BWC to process this request, you must provide a specific date. Please describe below the reason for the late reporting and/or late payment. You may attach a separate sheet if necessary. Please include any supporting documentation to substantiate your request. II. Governor's executive order one-time forgiveness An employer may request a one-time forgiveness under Gov. John Kasich's Executive Order 2011-01K if good cause cannot be shown for late payment and/or late reporting. The employer's lapse duration must be 59 days or less for the administrator to grant one-time forgiveness. Yes No I am requesting the Governor's Executive Order 2011-01K for consideration of a one-time forgiveness for the lapse date of: / / and penalty abatement. For BWC to process this request, you must provide a specific date. III. The request must be signed Employer (representative) signature Company name Date // Authorized Rep ID number BWC-7563 (Rev. March 7, 2016) U-59 American LegalNet, Inc. www.FormsWorkFlow.com