BUREAU OF WORKERS' COMPENSATION C-116 Mailed ________ (date) 30 West Spring Street Columbus, Ohio 43215-2256 SOLE PROPRIETOR OR PARTNER COVERAGE AGREEMENT INSTRUCTIONS-READ CAREFULLY This form is to be used only in cases where the Workers' Compensation Law of the State of Ohio is to be the exclusive remedy. One executed copy of this agreement is to be furnished to the Bureau of Workers' Compensation within ten days after it is executed. Only the sole proprietor or partner(s) signing will come within the terms of the agreement; any new partner requesting coverage must sign a similar agreement properly filed to be covered. The actual income of a sole proprietor or partner must be reported in the payroll report of the sole proprietorship or partnership at a weekly minimum of one hundred dollars ($100.00) and a weekly maximum not to exceed eight hundred dollars ($800.00) or twenty thousand, eight hundred dollars ($20,800.00) semi-annually, or an aggregate of forty-one thousand, six hundred dollars ($41,600.00) annually. Risk No. Name of Employer CENTRAL OFFICE USE ONLY Address Account Status ________________ C-116 Yes City, State, ZIP Code No Pursuant to the provisions of R.C. Section 4123.01, the sole proprietorship or partnership is to be bound by The Workers' Compensation Law of the State of Ohio, and it is mutually agreed that the proprietor or partner shall be entitled to compensation benefits regardless of where the injury occurred or where the disease was contracted. Sole proprietors and partners may elect to be covered, but they will be provided workers' compensation coverage only by signing a form C-116 agreement and paying premiums on earned income. WITNESS this agreement is between (Insert name of employer and state whether sole proprietorship or partnership) and the Bureau of Workers' Compensation that said sole proprietorship or partnership is subject to and has complied with provisions of The Workers' Compensation Law of Ohio. It is mutually agreed that this C-116 agreement shall remain in full force and effect, and the employer shall be responsible for the payment of premium thereon, until the sole proprietor or partner(s) requests termination of coverage, or until terminated by the bureau. In the case of a sole proprietor or partner(s), which fails to pay premiums timely coverage shall be terminated by the bureau. In the case of a sole proprietorship or partnership which reports payroll for its employees only, the failure to report payroll and to pay premiums for any person for whom coverage is elected shall terminate coverage for any such person only. In the event of termination of coverage for non-payment of premium, a sole proprietor or partnership may reinstate elective coverage only upon the filing of a subsequent application form (U-22). Reinstatement of coverage shall be effective only upon the receipt of the executed form (U-22) and payment of premium for such elective employees, and no retroactive coverage may be granted except as provided in Rule 4121-14-03 of the Administrative Code. BWC-1239 (Rev. 7/31/95) C-116 2000 © American LegalNet, Inc. The sole proprietor or partner(s) who elects coverage_____________ hereunto affix their signatures together with their residential address. Sole Proprietor or Partner(s) Name (Print or Type) Date of signing Signature of Sole Proprietor or Partner(s) Residential Address The employer, being duly authorized in the premises, hereunto affixes their signature at _________________________________________ , this _______ day of ___________________, 19 _____ CENTRAL OFFICE USE ONLY (Employer) (Effective Date) (Initials) (Title) 2000 © American LegalNet, Inc.