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Application For Transfer Of Workers Compensation Account And Premium Obligation To Succeeding Employer BWC-7511 - Ohio
|Application For Transfer Of Workers Compensation Account And Premium Obligation To Succeeding Employer Form. This is a Ohio form and can be used in Employers Workers Comp .||
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State of Ohio Bureau of Workers' Compensation Columbus, Ohio 43215-2256 APPLICATION FOR TRANSFER OF WORKERS' COMPENSATION ACCOUNT AND PREMIUM OBLIGATION TO SUCCEEDING EMPLOYER We, the undersigned, hereinafter referred to as former employer and succeeding employer, do hereby propose to the Industrial Commission of Ohio that the Workers' Compensation risk account, together with any merit rating accident cost experience connected with the business and risk account of the former employer be transferred to the succeeding employer. Further, we mutually agree to the transfer and agree to abide by the terms and conditions of the transfer. Further, we each make our respective representations and certifications as hereinafter set forth and jointly certify to the mutual requirements contained in this instrument. (If partnership list all partnersIf corporation state full corporate name and charter number, attach additional sheet if needed) Charter #____________ 1. Succeeding Employer's Name (First) (Middle) (Doing business as) (Last) (Phone No.) (Emp. Fed. ID No.) (State) (ZIP Code) (County) Trade name Mailing address (No. and Street) (City) Association Corporation *Individual *Partnership Check the above entity which applies Yes Yes No No *Do you presently have U-3S sole proprietor or partnership elective coverage ............ If yes, do you wish to continue U-3S coverage ....................................................... (A new U-3S Agreement will be forwarded for completion) If no, do you wish to elect sole proprietor or partnership U-3S coverage ................... (If yes, a new U-3S Agreement will be forwarded for completion) Former Employer's Name (First) (Middle) (Doing business as) (Last) (Emp. Fed. ID No.) (State) (ZIP Code) (County) Yes No 2. Trade name Mailing address (No. and Street) (City) Association Corporation Individual Partnership Check the above entity which applies 3. The succeeding employer hereby certifies that they are THE IMMEDIATE SUCCESSOR TO THE ENTIRE BUSINESS previously conducted by the former employer herein designated and desires to have transferred to them the workers' compensation risk account and experience of the former employer. The succeeding employer hereby agrees to assume the premium obligations of the former employer, and further agrees that the workers' compensation experience of the former employer be applied to the succeeding employer. They also agree to retain all payroll records of the former employer for the two year period prior to the date of transfer. The succeeding employer, in support of the request for transfer of the risk account, further certifies to the following statements: 4. (a) Is the succeeding employer insured in the State Fund ......................................................................... (b) The succeeding employer's State Fund Risk Number is Yes No 5. The succeeding employer will conduct the business in the same manner as conducted by the former employer with only the following exceptions: (a) Change in management personnel, methods of processes (b) Change in building, plant or equipment (c) Change in products or business DO NOT USE THIS SPACE (OVER) (Approved by) (Date completed) (Effective) BWC-7511 (Rev. 1/25/2000) U-9 Completion of this form is voluntary but failure to do so may result in a period of non-coverage and related penalties may result. 2002 © American LegalNet, Inc. 6. The former employer hereby certifies that they have transferred the business formerly conducted to the herein designated succeeding employer and desires to have transferred to the succeeding employer the workers' compensation risk account and experience of the former employer. The former employer hereby agrees to waive all rights to the risk account including premium security deposit and experience of the former employer. The former employer was at the time of transfer insured in the State Insurance Fund under Risk No. and was classified as follows: Manual No. Description of Industry 7. 8. 9. The change in ownership, entity or merger was effective . . . Month _______ Day _______ Year _______ Describe fully the purpose of the change in employers such as purchase and sale, retirement, silent partner, combining subsidiary with parent company, etc.: 10. In compliance with Section No. 3, does the succeeding employer have (or have available) all payroll records of the former employer for the last two years, or portion thereof, in his accountant's, bookkeeper's, attorney's, or personal possession? If records are not available, transfer cannot be approved and new coverage must be obtained by succeeding employer. 11. EACH OF THE SIGNATORIES HERETO HAVE READ THE TERMS UNDER WHICH THIS APPLICATION WILL BE CONSIDERED BY THE INDUSTRIAL COMMISSION AND EACH HEREBY AGREES TO BE BOUND THEREBY. THE PERSONAL SIGNATURE OF A CORPORATE OFFICIAL, OR ONE PARTNER IN CASE OF A PARTNERSHIP IS REQUIRED OF BOTH FORMER AND SUCCEEDING EMPLOYERS. IN CASE THE INDIVIDUAL IS DECEASED, THE SIGNATURE OF THE ADMINISTRATOR OR EXECUTOR OF THE ESTATE IS ACCEPTABLE. IDENTIFY CORPORATE OFFICERS BY TITLE AND NAME. IN CASE BOTH THE SIGNATURES OF THE FORMER AND SUCCEEDING EMPLOYERS ARE NOT AVAILABLE, TRANSFER CANNOT BE APPROVED AND NEW COVERAGE MUST BE OBTAINED BY SUCCEEDING EMPLOYER. NOTE IN TESTIMONY THEREOF, said former employer and succeeding employer have caused this instrument to be signed and witnessed this _____ day of _____________________ , __________. (Witness) (Former Employer) (Title) (Succeeding Employer) (Title) 2002 © American LegalNet, Inc.