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Agreement To Select A State Other Then Ohio As The State Of Exclusive Remedy BWC-1235 - Ohio

Agreement To Select A State Other Then Ohio As The State Of Exclusive Remedy Form. This is a Ohio form and can be used in Employers Workers Comp .
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AGREEMENTTELET ATATETERTANIHA Better Workers Compensation Built with you in mind. TETATEFEXLUIVEHREMEDY INTRUTIN-READAHREFULLY Cerfce of coverge of suc oer segs sll be ced og s Areemen. In gcses were Oo s go be e exclusve rgemedy use form C-110. One execued copy ofg s Areemen s o gbe furnsed o e Ungderwrn Secon ofg e Bureu of Workergs Compenson wn en dys fer s gexecued. Only employees snn gwll come wn e germs of e reemeng; ny new employees og be ncluded n sucg reemens mus sn sepre Areemeng. Ts form s prmrly nended o be sned by severl employees of e employer. However, were crcumsnces demnd, ndvdul reemens my be compleed. Due o dmnsrve requremens, e employer mus obn n Oo Workers Compenson ccoun nd mnn e ccoun n n cve sus o vlde s Areemen. Rsk No. Nme of Employer Address CySe Zp Code AGREEMENT PURSUANT TO R.C. 4123.54. Revsed Code Secon 4123.54. "Every employee, wo s njured or wo conrcs n occuponl dsese, nd e dependens of e cemployee wo s klled, or des s e resul of n occuponl dsese conrced n e course of employmen, werever suc njury s occurredor occuponl dsesge s been conrcedg, provded e sme wegre no: (A) Purposely self-nflcegd; or (B) Cused by e employeeg ben noxced or gunder e nfluence gof conrolled subgsnce no prescrbedg by pyscn were e noxcon or ben under e nfluence of e conrolled subsnce no prescrbed by pyscn ws e proxme cuse of e njury, s enled o receve, eer drecly from s employer s provded n secon 4123.35 of e Revsed Code, or from e se nsurnce f und, ecompenson for loss susned on ccoun of e njury, occuponl dsese or de, nd e medcl, nurse, nd ospl s ervces ndmedcnes, nd e mgoun of funerl expegnses n cse of deg, s re provded by gs cper. Wenever, w respec o n employee of n employer wo s subjec o nd s compled w secons of s cper, ere s possblyof conflc w respegc o e pplcon ofg workers compensong lws becuse e cognrc of employmen gs enered no nd ll or some poron of e work s or s o be performed n se or ses oer n Oo, e employer nd e employee my ree o b e bound by elws of s se or by e lws of some oer se n wc ll or some poron of e work of e employee s o be perfor med. Te reemen sll be n wrn nd sll be fled w e Bureu of Workers Compenson wn en dys fer s execued nd sll remn n force unl ermned or modfegd by reemen of e gpres smlrly fledg. If e reemen gs o be bound by e glws of s se nd e employer s compled w s cper, en e employee s enled o compenson nd benefs rerdless of were e njury occur s or e dseses conrced nd e rs of e employee nd s dependens under e lws of s se sll be e exclusve remedy frfn ns e employer on ccoun of njury, dsese, or de n e course of nd rsn ou of employmen. If e reemen s o be bound by e lws of noer se nd e employer s compled w e lws of se, e rs of e employee nd s dependens under e lws o f se sll be e exclusve remedy ns e employer on ccoun of njury, dsese, or de n e course of nd rsn ou of s em ploymen wou rerd o e plce wegre e njury ws susgned or e dsese gconrced. If ny employee or s dependens re wrded workers compenson benefs or recover dmes from e employer under e lw s ofnoer se, e moun wrded or recovered, weer pd or o be pd n fuure nsllmens, sll be creded on e mo un of ny wrd of compenson or begnefs mde o e emgployee or s dependengs by e bureu. If ny employee s rgesden of se oger n s se nd gs nsured under eg workers compensong lw or smlr lws of se oer n s se, e employee nd s dependens re no enled o receve compenson or benefs under s cper, on ccoun of njury,dsese or de rsn ou of or n e course of employmen wle emporrly wn s se nd e rs of e employ ee nd s dependens under e lws of eg oer se sll be ge exclusve remedy gns e employer ong ccoun of e njuryg, dsese, or de." Te erm "njury" s used n s secon nd n e workers compenson c sll nclude ny njury receved n e course of, nd rsn ou of, e njured emgployees employmen. WITNESS s reemeng beween (Inser nme of emplogyer nd se weer gndvdul, co-prnersgp or corporon.) employer, nd e employees of sd employer, wose snures pper on s reemen. Sd employer represens o e Bure u of WorkersCompenson sd egmployer s subjec o gnd s compled w ge provsons of e Wgorkers Compenson Lgw of Oo. BWC-123R.2/24/2v000) Compleon of s form s volunry nd wll expede processn of nformon requesedC-112 necessry for proper gdeermnon of Oogs jursdcon n s gmer American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Te pres o s reemen represen o e Bureu of Workers Compenson ere s possbly of conflc w respe c o epplcon of e Workers Compenson Lws becuse e conrc of employmen s enered no nd ll or some poron of e work s, ors o be, performed gn dfferen ses, wgc ses pper belowg oppose e employeesg nmes. Terefore, n vew of e foreon nd pursun o e provsons of R.C. Secon 4123.54, e employer nd sd employees mu ully reeo be bound by e Workers Compenson Lw of e se, wc ppers oppose e nmes of e vrous employees; nd s muully reed rerdless of were e njury occurred or were e dsese ws conrced, e rs of e employee(s) nd s, er, o r er dependenssll be overned by e lws of e se or ses eren reed upon, nd e lws of se or ses sll be exclusv e remedy ns eemployer on ccoun of njury, dsese or de n e course of nd rsn ou of employmen. Te employer represens o e Bureu of WorkersCompenson e, egy or , s compled wg e Workers Compengson Lws of e folglown se or sesg, (Inser ere e nme gof e se or sesg reed upon) nd premums ve been pd s provded by lw nd covere s now n full force nd effec n sd se or ses, n c cordnce w eCerfces of Covere on e se or ses menoned bove, wc cerfces re ereo ced nd mde pr ereof. UnlessthisertificateofoverageiHsfiled,theAgreementHisnotinforce. I s muully reed s reemen sll remn n full force nd effec unl ermned or modfed by reemen of bt e pres smlrlyfled s n s reegmen. Te employees of (Inser nme of emplogyer) ereuno ffx er snures oeer w er resdences, de of snn nd plce of snn nd e nme of e Se or Ses n wcwork s, or s o be, gperformed. PrintName,Plus Residence Date tateof tateinwhichwork tatewherecontract Exclusive is,oristobe ofemploymententered ignatureofEmployee ityandtate igned Remedy performed intocannotbehio Te employer, ben dugly uorzed n e pregmses, ereuno ffxegs s, er or s sngure _________________________________________ s _________ dy of ____________________________________________ , _______ (Employer) By (Tle) American LegalNet, Inc. (ThisAgreementmustbesHignedbytheowner,partnerH,orofficerifacorporatiHon.) www.USCourtForms.com
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