Settlement Application for Non-complying Employer Claims Ohio Administrative Code 4123-14-05 � Theemployerortheemployer'srepresentativeusesthisformtorequestadecisionbytheAdjudicatingCommitteetosettletheemployer's non-complianceliabilitytothestateinsurancefund. � Theemployermustsignandhavethisrequestnotarized. � Attachcurrentfinancialinformation(acopyofthepastthreeyears,federalandstateincometaxreturns)tothisapplication. � Mailcompleted,signedandnotarizedformto:BWC,LegalOperations,SettlementUnit,P.O.Box15398,Columbus,OH43215-0398, orsendafaxto614-719-5941.Pleasecall614-752-9040withquestions. Employername EmployerContactname Streetaddress City Injuredworkername Streetaddress Claimnumber(s) City State ZIPcode Telephonenumber () Policynumber Faxnumber () E-mailaddress State ZIPcode 1. StatereasonswhyasettlementwouldbeinthebestinterestofboththeapplicantandtheStateofOhio. 2. Numberofemployeeshiredbyapplicant: 3. Locationofemployerbusiness: 4. Lengthoftimeemployerhasbeeninbusiness: 5. Natureandtypeofemployerbusiness: 6. Pleaseexplainwhytheemployerdidnothaveworkers'compensationcoveragewhentheinjuredworkerwasinjured. 7. Dollaramountemployerproposestopayforsettlement:$ Note:Paymentarrangementsmayberequested. 8. Istheemployerpresentlycarryingworkers'compensationcoverage?YesNoIfno,pleasestatethereasonwhy. 9. Additionalinformationyoufeelisrelevanttoyourrequest: Attachments(pleaselist): The information contained in said application is true to the best of my knowledge. Officer'ssignature Title Date Sworn to before me and signed in my presence this ________ day of _________________ , ________. Notary Public, State of BWC-3516 (4/19/2002) LEGAL-16 American LegalNet, Inc. www.FormsWorkFlow.com