Application For Elective Coverage {BWC-7613}

Application for Elective Coverage Have questions? Need assistance? BWC is here to help! Call 1-800-644-6292, and listen to the options to reach a customer service representative. You can dial the number nationwide, and in Canada and Mexico from 7:30 a.m. to 5:30 p.m. EST. Remember, you can access information and request services by visiting BWC's Web site at www.bwc.ohio.gov If you do not have an existing policy with BWC, please complete the Application for Ohio Workers' Compensation Coverage (U-3) instead of this form. STOP! All employers with one or more employees must carry workers' compensation coverage. It's the law. However, Ohio law makes coverage elective for owners or ministers in one of the following categories: Sole proprietor; partnership; limited liability company acting as a sole proprietor; limited liability company acting as a partnership; family farm corporate officers; individual incorporated as a corporation; and ordained or associate ministers of a religious organization. These individuals may cover themselves by submitting this form. Elective coverage is effective the date BWC receives the application. You must complete an additional application for elective coverage to cover owners or ministers you wish to add at a later date. Remember, if you choose not to cover yourself and you are injured at work, BWC will not provide coverage, and other insurance may not cover your work-related disability or medical bills. Contact your insurance carrier if you have questions. Payroll reporting requirements Specific payroll reporting requirements associated with elective coverage are listed below. Sole proprietors and partners (including limited liability companies acting as a sole proprietor or partnership): For all individuals electing coverage, the reportable wages are subject to a minimum and maximum, which is based on the statewide average weekly wage (SAWW) calculated annually by the Ohio Department of Job and Family Services (ODJFS.) The minimum payroll reporting limit will be 50 percent of the SAWW and the maximum payroll reporting limit will be 150 percent of the SAWW. Individuals who earn between the minimum and maximum will report their actual net incomes based on their form 1040, Schedule C for sole proprietors, or form 1065 Schedule K-1 for partnerships, inclusive of any draws. Officers of a family farm corporation: For corporate officers of a family farm electing coverage, the reportable wages are subject to a minimum and maximum, which BWC bases on the SAWW calculated annually by the ODJFS. The minimum payroll reporting limit will be 50 percent of the SAWW and the maximum payroll reporting limit will be 150 percent of the SAWW. Officers of a corporation who earn between the minimum and maximum will report their actual W-2 wages. For S-corporations, officers must report wages for services they perform. This may include W-2 wages as well as all or part of ordinary income from Schedule K-1 up to the maximum. Religious Organizations: Ohio law requires religious organizations to cover their paid employees. However, BWC does not consider ordained ministers and associate ministers employees for the purpose of workers' compensation. When a minister is covered under the religious organization's policy, actual earnings are reportable and are not subject to the minimum and maximum. Ministers not covered under the religious organization's policy can complete an application for coverage and elect coverage on themselves as a sole proprietor. Ministers electing coverage as a sole proprietor are subject to the minimum and maximum reporting requirements as described above. Individuals incorporated as a corporation (with no employees): For individual corporate officers electing coverage, the reportable wages are subject to a minimum and maximum, which BWC bases on the SAWW calculated annually by the ODJFS. The minimum payroll reporting limit will be 50 percent of the SAWW and the maximum payroll reporting limit will be 150 percent of the SAWW. Officers of a corporation who earn between the minimum and maximum will report their actual W-2 wages. For S-corporations, officers must report wages for services they perform. This may include W-2 wages as well as all or part of ordinary income from Schedule K-1 up to the maximum. Note: Visit BWC's Web site, www.bwc.ohio.gov, or call BWC to obtain the minimum and maximum payroll reporting requirement amounts applicable for each payroll reporting period. Elective coverage type Sole proprietor Partnership Family farm corporate officers Legal business name Trade name or doing business as name Mailing address E-mail address BWC-7613 (combines U-43, U-136 and C-116) Street Limited liability company acting as a sole proprietor Ordained or associate minister of a religious organization Limited liability company acting as a partnership Individual incorporated as a corporation Policy number Federal employer identification number or Social Security number City State Telephone number ZIP code U-3S Rev. 10/27/2006 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Owners/ministers information ­ list owners/ministers electing coverage. (attached additional sheets if necessary.) Name #1 Residential address City Social Security number Duties Name #2 Residential address City Social Security number Duties Name #3 Residential address City Social Security number Duties Name #4 Residential address City Social Security number Duties State Title ZIP code State Title ZIP code State Title ZIP code State Title ZIP code Certification ­ signature required By my signature, I certify I have the authority to execute this application, and the facts set forth on this application are true and correct to the best of my knowledge and belief. I am aware that any person who does not secure or maintain workers' compensation coverage and pay all appropriate premiums in accordance with Ohio laws or misrepresents, conceals facts, or makes false statements to obtain coverage may be subject to civil, criminal and/or administrative penalties. Print name Signature and title Date WaRNINg: Insurance is not in effect until BWC receives the completed application. Mail completed form to: Ohio Bureau of Workers' Compensation Policy Processing Department, 22nd Floor 30 W. Spring St. Columbus, OH 43215-2256 apply for or cancel supplemental coverage online at: www.bwc.ohio.gov BWC use only Policy number Effective date Date received Initials Manual class number(s) U-3S Page 2 of