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Professional Employer Organization Client Relationship Notification BWC-8003 - Ohio
| Professional Employer Organization Client Relationship Notification Form. This is a Ohio form and can be used in Employers Workers Comp . |
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Professional Employer Organization Client Relationship Notification Instructions Use this form to notify BWC of a new client, change of relationship with a current client or termination of a client. nd Mail form to BWC, PEO Unit, 22 Floor, 30 W. Spring St., Columbus, OH 43215-2256, or send a fax to 614-719-5925. SI PEO: Email form to SIINQ@bwc.state.oh.us, or send a fax to 614-621-2032. Notice: BWC must receive new contract notification within 30 days of the effective date of the contract. BWC must receive contract termination notifications within 14 days of the effective date of the termination. Professional employer organization (PEO) information Company name Contact person name Policy number Telephone number Client company information Check only one New client information Contract termination information Client company name DBA Mailing address (P.O. Box if applicable) City Change of policy number reporting client payroll/claim Change to portion of client's employees assumed by PEO Effective date of contract, termination or change in Ohio Client policy number Federal ID number Client phone number State Nine-digit ZIP code Employee reporting (payroll and claims) All under the PEO policy A portion under the PEO policy All under the client policy List class codes reportable by PEO PEO List class codes reportable by client Client Signatures are required by both parties Print client signatory Title Date Client signature Print PEO signatory PEO signature Note: Signing this form is an acknowledgement that all the information listed on this form is complete and true to the best of your knowledge. Omission of any of the items required or intentional misrepresentation of any of the above information on this form may lead to registration revocation as outlined in Ohio Revised Code Section 4125. BWC-8003 (Rev. 6/11/2012) PC UA-3 American LegalNet, Inc. www.FormsWorkFlow.com
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