Request to Charge the Surplus Fund for Non - At - Fault Motor Vehicle Accident BWC - 0529 (Rev. Aug. 21 , 2018 ) AC - 28 Instructions This application details the required documentation a private employer or public employer taxing district must provide to support a request for experience modification calculation . Submitting the r equired documentation with this form will help BWC make a quicker deci sion. BWC will advise you if it needs additional docume ntation or information . Fax this completed form and requir ed supporting evidence to 614 - 621 - 1217 , or submit it by mail to BWC, 30 West Spring St. , Attn: Rate Adjustment Departm ent 25 th floor, Columbus, OH 43215 - 2256. You may email questions concerning the motor vehicle experience adjustments to emprateadj@bwc.state.oh.us . Injured worker information Name Claim number Date of i njury If applicable, date of death Responsible third party information Name Address Telephone number City State ZIP code E mail address Required supporting docu mentation that you must submit with this application includes: Copy of the police motor vehicle accident report from a law enforcement agency ; and Copy of the citation showing the third party is responsible for this accident or, in the absence of a citation, evidence that the third party is primarily liable for this accident. Insurance i nfo rmation of responsible third party Insurance company name Fax number Address Telephone number City State ZIP code Email address Required supporting documentation that you must submit with this application includes: Proof of thi rd - party insurance or a surety bo nd through any of the following; o Auto Insurance ID card; o Declaration Page; o O ther proof of coverage; Proof that the insurer accepts liability. Employer representative information Employer representative name Representative ID number Address Telephone number City State ZIP code E mail address Employer of record information Employer name requesting experience modification Policy number Manual number Address Telephone number City State ZIP code E mail address Signa ture I have been authorized to sign and execute this application for experience modific ation on behalf of the company. I have read and understand the experience adjustment requirements in their entirety and agree to comply with the terms. I understand i f all of the required information and supporting documentation are not submitted BWC may deny this application. Name of applicant filing for the employer Date American LegalNet, Inc. www.FormsWorkFlow.com