Ohio > Workers Comp > Employers
Application For Renewal Of Authorization To Operate As A Self-Insured Risk BWC-7207 - Ohio
| Application For Renewal Of Authorization To Operate As A Self-Insured Risk Form. This is a Ohio form and can be used in Employers Workers Comp . |
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Application for Renewal of Authorization to Operate as a Self-insured Risk (as outlined in Ohio Revised Code Section 4123) Renewal date Self-Insured risk number Instructions · Please answer all questions. If not applicable, use symbol N/A. · You must ile all requests for data and inancial statements, or BWC will return the application as incomplete. · Mail this form to: ATTN: Self-Insured Department, Ohio Bureau of Workers' Compensation 30 W. Spring St., 27th Floor, Columbus, Ohio 43215-2256 Company Information Employer name (shown exactly as it is in the Articles of Incorporation) Federal I.D. number Address Number of Ohio employees as of application date City County State Nine-digit ZIP Code Corporate contact person Corporate phone number ( ) Corporate FAX number ( ) Type of entity (check appropriate box) Corporation Association Partnership Sole proprietor State of incorporation Date of incorporation Complete This Section If Applicable Name of ultimate USA parent (show exactly as it is in the Articles of Incorporation) Ultimate USA parent Federal I.D. number State of incorporation Date of incorporation Percentage of ownership Please attach a detailed organizational chart, if applicable. % Subsidiary Information Please list subsidiary corporation(s) in Ohio, authorized by the Bureau to operate under this self-insured risk number. Authorized subsidiaries are listed on the Certificate of Employer's Right to Pay Compensation Directly. If an entity does not appear on your certificate, you must file an initial application for self-insurance with the self-insured department. Organization name Incorporation date State in which incorporated Employer federal I.D. number BWC-7207 (Rev. 1/29/2009) SI-7 American LegalNet, Inc. www.FormsWorkFlow.com Excess Workers' Compensation Insurance Does your company carry excess workers' compensation insurance? Name of carrier: Name of agent: Policy number: Telephone number: ( ) Yes No Representative Information Name of person or organization to whom renewal correspondence should be directed per AC-2 form Telephone number ( Name of attorney or service representative, if any ) Telephone number ( ) Corporate Restructuring Has your corporate name, structure or address been revised during the past year? Explain: Yes No Merger Asset purchase Name revision Other Please note: For BWC to properly process the above referenced revisions, please provide secretary of state papers and board of director documents to the above listed address. For requested financial information please see the attached Important Update Request Ohio assets $ Calendar and/or iscal year ending Ohio gross payroll $ Certification (Notary seal) (Corporate seal) State of ____________________ County of _______________________ ss_____________________________ being duly sworn says that he/she is the ___________________________ of _______________________ , the employer referred to in the foregoing is true to the best of their knowledge. Sworn to before me, this _____ day of _________________ , 19 _____ Notary signature Corporate oficer signature American LegalNet, Inc. www.FormsWorkFlow.com Instructions · 1. If you ind no discrepancies please indicate this and return this form with your packet. · 2. Indicate all locations where you maintain claims records for auditing purposes. · 3. Indicate all claims locations, which have been closed or sold, and the effective dates. In addition, please designate the Ohio location that will administer the claims. · 4. You must use the division codes assigned to your various locations when iling claims. Information Update Request Self-insured Risk No. Company: Telephone number ( ) This form completed by Name and title Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Yes No Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Yes No Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Additional locations on reverse side Yes No BWC-7207 (Rev. 1/29/2009) (SI-220 comb. within) SI-7 Pg. 2 American LegalNet, Inc. www.FormsWorkFlow.com IMPORTANT NOTICE: When iling claims, use the division codes assigned to your various locations. Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Yes No Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Yes No Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Yes No Company: DBA/Division: Attention: Telephone number: Address: Check if there are no changes Claim files maintained Yes No American LegalNet, Inc. www.FormsWorkFlow.com
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