Settlement Application For Non-complying Employer Claims {BWC-3516}

BWC-3516 / LEGAL-16 - SETTLEMENT AGREEMENT AND APPLICATION FOR APPROVAL OF SETTLEMENT AGREEMENT. The employer or the employer’s representative uses this form to request a decision by the Adjudicating Committee to settle the employer’s non-compliance liability to the state insurance fund. The employer must sign and have this request notarized. Attach current financial information (a copy of the past three years’ federal and state income tax returns) to this application. Mail completed, signed and notarized form to: BWC, Legal Operations, Settlement Unit or send a fax. www.FormsWorkflow.com