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One Time Lump Sum Settlement (LSS) Exclusion Program For Public Employer State Agencies BWC-7650 - Ohio
| One Time Lump Sum Settlement (LSS) Exclusion Program For Public Employer State Agencies Form. This is a Ohio form and can be used in Employers Workers Comp . |
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One-Time Lump Sum Settlement (LSS) Exclusion Program for Public Employer State Agencies INSTRUCTIONS: This One-Time LSS Exclusion Program (One-Time Exclusion) is available to those public employer state (PES) agencies that are not currently participating in a settlement payment program. State agencies may NOT participate in the One-Time Exclusion while also participating in the LSS Direct Reimbursement Payment and Rating Program (LSS Program). Eligible state agencies that wish to choose both LSS progra ms must first enroll in the One-Time Exclusion and must conclude settlements on identified claims by June 30, 2006. The One-Time Exclusion is limited to two years and will then expire. Eligible state agencies may then choose to enroll in the LSS Program at a later date. Applications must be submitted by July 1. On page 2 of this application form, the state agency must submit a comprehensive list of claims that the agency plans to settle by June 30, 2006, and wishes to have the settlement payments excluded from the rating process. Return completed form to BWC Employer Progra ms, L-22, 30 W. Spring St. Columbus, OH 43215. Agency name Policy number Address City State 9-digit ZIP code - County Office telephone number Fax number ( ) ( ) E-mail address Effective date of participation / / I affirm that the information provided on this form is accurate to the best of my knowledge. I further affirm that I have the authority to sign this application form as a designated executive re presentative of my agency and that by my signature below I commit my agency to follow all rules a nd procedures relative to this program. Printed or typed name of executive staff signing this application Title of person signing this application Signature of designated executive staff Date BWC-7650 (Rev 6/2/04) PC American LegalNet, Inc.U-144 www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Claims Information (Claims agency plans to settle and wants settlement payments excluded from rate calculation process) Claim number Injury date Injured worker last name, first name Injured worker SSN / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / BWC-7650 (Rev 6/2/04) PC U-144 American LegalNet, Inc. www.USCourtForms.com
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