Ohio > Workers Comp > Employers
Application For The Premium Discount Program BWC-8005 - Ohio
| Application For The Premium Discount Program Form. This is a Ohio form and can be used in Employers Workers Comp . |
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Ohio Bureau of Workers' Compensation Application for Instructions · Complete the application. · Anofficer,partner,orowner(soleproprietor)mustsigntheapplication. · Pleasetypeorprintclearly. · Faxcompletedapplicationto(614)365-4976bythedeadlinebelow. Choose one of the program dates below. BeginningJan.1,20______(Jan.1-Dec.31) BeginningJuly1,20______(July1-June30) Please obtain and retain proof of successful transmission. Employername Policynumber Tradename/DBA Fax () Officetelephonenumber () FederalI.D.number Streetaddress(Please list additional locations in Ohio on reverse side.) E-mailaddress City State Nine-digitZIPcode County Safetyplancoordinator Alternatesafetyplancoordinator NumberofemployeesinOhio Fulltime Parttime ·This application is intended for first-time applicants, ·Employersinthefirstyearmustcompleteandpasssteps1, employershavingaone-yearabsencefromtheprogramwho 2,6andanytwooftheremainingsevensteps.Participants wanttoreactivateparticipationandemployersreapplying also must attend any of BWC's pre-approved Division of forthetwoyearextension. Safety&Hygiene'scourses,Workers'CompUniversity,The OhioSafetyCongress&Expo,orpublicorprivatecourses ·EmployersparticipatingeffectiveJuly1mustsubmitaPlan pre-approved by BWC to satisfy the Step 6 requirement. ofActionandSelf-Assessmentwithappropriatesupporting documentationbyMarch31toBWC.Employersparticipating Employersintheremainingyearsmustcompleteandpassall effective Jan. 1, must submit a Plan of Action and Self10stepsofthe10-StepBusinessPlanincludingattendance Assessmentwithappropriatesupportingdocumentationby atanapprovedStep6class. Sept.30,exceptforpublicschooldistricts,whicharedue byNov.15.FailuretocompleteaPlanofActionandSelfAssessmentbytheindicateddeadlinewillresultinretroactive lossofthediscounttothebeginningofthepolicyyear. I understand BWC will revoke the discount to the beginning of the policy year if we do not submit a Plan of Action and Self-Assessment. I understand that continued participation in the Premium Discount Program Plus is contingent on the successful implementation of BWC's 10-Step Business Plan. Officername Signature Certified sponsor (if applicable) Certifiedsponsorassociationname Officertitle Date BWC USE ONLY Effectivedate Initials BWC-8005(Rev.1/16/2008) UA-5 American LegalNet, Inc. www.FormsWorkflow.com ATTENTION EMPLOYER PROGRAMS UNIT L-22 BUREAU OF WORKERS COMPENSATION 30 W SPRING ST COLUMBUS OH 43215-2256 s432152256307s FOLD HERE. DO NOT STAPLE USE TAPE, GLUE OR TAB TO SEAL FAXcompletedapplicationto(614)365-4976.Pleaseobtainandretainproofofsuccessfultransmission. Contact person Address City Telephone number General or district manager State Nine-digit ZIP Code County Contact person Address City Telephone number General or district manager State Nine-digit ZIP Code County Contact person Address City Telephone number General or district manager State Nine-digit ZIP Code County FOLD HERE FIRST · To better service your account, please attachlocations. additional sheets as needed listing all Ohio FOLD INSIDE ONLY American LegalNet, Inc. www.FormsWorkflow.com
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