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Agreement To Select The State Of Ohio As The State Of Exclusive Remedy BWC-1233 - Ohio

Agreement To Select The State Of 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 Better Workers Compensation TETATEFIATE Built with you in mind. TATEFEXLUIVEREMHEDY INTRUTIN-READARHEFULLY This fo o b sd uonly wh h Woksu Copnsaion Law ouf Ohio is o b xclusiv dy. On xcd copy of uhis Agn o b fnuishd o h Undwiiung Scion of h Ba uof Woks Copnsauion wihin n days af i is uxcd. Only ploys signing will co wihin h s of h agn; nw ploys o b incldd in sch agn s sign a siila agn, which agn s likwis bu signd by h ployu and siilaly filud. This fo is piaily inndd o b signd by sval ploys. Howv, wh cicsancs dand, individal agns ay b xcd on his fo. Addiional copis wuill b fnishd on uqs. This agn can onluy b sd wh h puloy has cn Ohiou Woks Copnsaioun covag in ffc. Risk No. __________________ Na of Eploy Addss Ciy Sa Zip Cod AGREEMENT PURSUANT TO R.C. 4123.54. Rvisd Cod Scion 4123.54. "Evy ploy, who is injd o who conacs an occpaional disas, and h dpndns of achploy who is killd, o dis as h sl of an occpaional disas conacd in h cos of ployn, whv sch injy has occd o occpaional disuas has bn conacud, povidd h sa wu no: (A) Pposly slf-inflicud; o (B) Casd by h ploy bing inoxicad o nd h inflnc of a conolld sbsanc no pscibd by a physician wh hinoxicaion o binug nd h inflnc ouf h conolld sbsuanc no pscibd buy a physician was uh poxia cas ofu h injy, is nild o civ, ih dicly fo his ploy as povidd in scion 4123.35 of h Rvisd Cod, o fo h sa insanc fnd, h copnsaion fo loss ssaind on accon of h injy, occpaional disas o dah, and h dical, ns, and hospi al svics anddicins, and h aoun of fnal xpnsus in cas of dah, aus a povidd by hius chap. Whnv, wih spc o an ploy of an ploy who is sbjc o and has coplid wih scions of his chap, h is possibiliyof conflic wih spc o h applicaion of woks copnsaion laws bcas h conac of ployn is nd ino an d all o sopoion of h wok ius o is o b pfoud in a sa o sasu oh han Ohio, h uploy and h plouy ay ag o b bond by h laws of his sa o by h laws of so oh sa in which all o so poion of h wok of h ploy is o b pfo d. Th agn shall b in wiing and shall b fild wih h Ba of Woks Copnsaion wihin n days af i is xcd and shall ain in foc nil inad o odifid by agn of h pais siilaly fild. If h agn is o b bond by h laws of his sa and h ploy has coplid wih his chap, hn h ploy is nild o copnsaion and bnfis gadlss of wh h injy occ s o h disas is conacd and h ighs of h ploy and his dpndns nd h laws of his sa shall b h xclsiv dy agai ns h ploy on accon of injy, disas, o dah in h cos of and aising o of his ployn. If h agn is o b bond by h laws of anoh sa and h ploy has coplid wih h laws of ha sa, h ighs of h ploy and his dpndns nd h laws o f ha sa shallb h xclsiv dy agains h ploy on accon of injy, disas, o dah in h cos of and aising o of his ft ployn wiho gad o h plac whu h injy was ssauind o h disas cuonacd. If any ploy o his dpndns a awadd woks copnsaion bnfis o cov daags fo h ploy nd h law s ofanoh sa, h aon awadd o covd, whh paid o o b paid in f insallns, shall b cdid on h ao n of any awad of copnsaion o bunfis ad o h puloy o his dpndnus by h ba. If any ploy is a sidn of a sa oh han his sa and is insd nd h woks copnsaion law o siila la ws of a saoh han his sa, h ploy and his dpndns a no nild o civ copnsaion o bnfis nd his chap, on accon of injy,disas o dah aising o of o in cos of ployn whil poaily wihin his sa and h ighs of h ploy a nd his dpndns nd h laws of h uoh sa shall b uh xclsiv dy agauins h ploy on auccon of h injy, duisas, o da h." Th "injy" as sd in his scion and in h woks copnsaion ac shall incld any injy civd in h cos of, and aisingo of, h injd pluoys ployn. WITNESS his agn bwun (Ins na of ployu and sa whh induividal, co-panshiup o copoaion.) ploy, and h ploys of said ploy, whos signas appa on his agn. Said ploy psns o h Ba of Woks Copnsaion ha saiud ploy is sbjc uo and has coplid uwih h povisions uof h Woks Copnusaion Law of Ohio.u BWC-12R.2/16/20v00) Coplion of his fuo is volnay and uwill xpdi pocssuing of infoaion qusd ncssay fo pop duinaion of Ohious jisdicion in hius a C-110 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Th pais o his agn psn o h Ba of Woks Copnsaion ha h is possibiliy of conflic wih sp c o happlicaion of h Woks Copnsaion Laws bcas h conac of ployn is nd ino and all o so poion of h wok is, ois o b, pfod in udiffn sas, whichu sas appa blow uopposi h ployus nas. Thfo, in viw of h fogoing and psan o h povisions of R.C. Scion 4123.54, h ploy and said ploys trn allyag o b bond by h Woks Copnsaion Law of h Sa of Ohio; and i is ally agd ha h ploys shall b nild ocopnsaion bnfis gadlss of wh h injy occd o wh h disas was conacd, and h ighs of h ploy (s) and his,h, o hi dpndns nd h laws of h Sa of Ohio shall b h xclsiv dy agains h ploy on accon of i njy, disas odah in h cos ofu and aising o of uployn. I is ally ag ha his agn shall ain in fll foc and ffc nil inad o odifid by agn of h paissiilaly fild as iun his agn. Th ploys of (Ins na of ployu) hno affix hi signas ogh wih hi sidncs, da of signing and plac of signing and h na of h Sa o Sas in whichwok is, o is o b, upfod. PrintName,Plus Residence Date tatewherecontractof tateortates ignatureofEmployee ityandtate igned employmententered inwhichworkis, intocannotbehio oristobeperformed Th ploy, bing dluy ahoizd in h puiss, hno affixsu his, hi o is siguna a his day of , (Eploy) (Til) American LegalNet, Inc. www.USCourtForms.com (This Agn s b suignd by h own, paun, o offic if a ucopoaion.)
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