Ohio > Workers Comp > Employers
Agreement For Construction BWC-7611 - Ohio
| Agreement For Construction Form. This is a Ohio form and can be used in Employers Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Opt Out of .99 EM Construction Cap Program Please return by Oct. 31 Legal business name BWC policy number** Primary physical location City State ZIP code Phone Fax Email** Pursuant to Amended Substitute House Bill 15, BWC will give an eligible employer the temporary .99 EM* unless the employer decides not to participate (opts out). This .99 EM will not change the employer's actual rate. BWC will calculate the actual rate based on the employer's claims experience consistent with the calculations used for all Ohio employers. Should you decide to participate in the .99 EM Construction Cap Program and receive a temporary .99 EM, you must: Work with a BWC safety consultant to implement a safety program similar to BWC's 10-Step Business · Plan for Safety; · · Have an implementation plan in place by Nov. 30; Be responsible to pay full premium based upon actual calculated EM for the company. Instructions · · · · Please type or print clearly. Only an officer, partner or owner may sign this agreement. If you want to remain in this program, disregard this notice. Send a signed, completed form via fax to 614-621-1405 by Oct. 31, 2011. You may also mail this agreement to Employer Programs, BWC, 30 W. Spring St., 22nd Floor, Columbus, OH 43215. Please retain a copy for your records and proof of successful fax transmission. I, the undersigned, do hereby agree to opt out of the .99 EM Construction Cap program. Officer/partner/owner Title Officer/partner/owner signature Date * Temporary .99 EM Construction Cap does not affect employer's rates. ** BWC policy number is required to process the OPT OUT request. BWC-7611 (Rev. 9/14/2011) PC U-108 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
