Ohio > Workers Comp > Employers
Private Employer Agreement For 100 Percent EM Cap BWC-7521 - Ohio
| Private Employer Agreement For 100 Percent EM Cap Form. This is a Ohio form and can be used in Employers Workers Comp . |
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Private Employer Agreement for 100-percent EM Cap Please return by Sept. 30, 2011 Instructions · Eligible employers must complete and return this agreement to BWC by Sept. 30, 2011. · Please type or print clearly. · An officer, partner or owner must sign this agreement. · Send a completed agreement via fax to 614-365-4976. You may also mail this agreement to: BWC, 30 W. Spring St., 22nd Floor, Columbus, OH 43215. · Please retain a copy for your records and proof of successful fax transmission. Legal business name Primary physical location Phone Fax City E-mail State BWC policy number ZIP code · We will cap or limit the July 1, 2011, experience modification (EM)% at a 100-percent increase from the published July 1, 2010, EM percent. We will not adjust the July 1, 2010, published EM percent for the purposes of determining the cap for the July 1, 2011, rating year. We will not apply a cap to any EM-percent decreases. · Employer requirement To be eligible for the cap in the first policy year, an employer must complete steps one, two, six and any other two steps of the 10-Step Business Plan for Safety of rule 4123-17-70 of the Ohio Administrative Code. The employer shall submit the required documentation by March 31, 2012. To effectively control your workers' compensation costs, you must use the latest claim-management techniques. For assistance with implementing the 10-Step Business Plan for Safety and other claims management techniques, contact your local customer service office or a BWC-certified, 10-Step Business Plan for Safety sponsor. Please note Employers must implement steps one, two and six and any other two steps of the 10-Step Business Plan for Safety during the first year. During year two and beyond, all 10 steps must be implemented and improvement must be demonstrated. If you fail to comply with these requirements, BWC will remove the cap for the policy year in which the requirements were not met. · Eligibility for participation The employer shall be current as of June 1 immediately prior to the policy year to which the cap will be applied (not more than 45 days past due) on any and all premiums, assessments, penalties or monies otherwise due to any fund administered by BWC, including amounts due for retrospective rating. The employer cannot have cumulative lapses in workers' compensation coverage in excess of 40 days within the 12 months preceding June 1 immediately prior to the policy year to which the cap will be applied. We will only apply the cap to a policy that has an initial published July 1, 2011, EM of 1.01 or greater. Any subsequent adjustments to the initial published EM will not affect the employer's cap eligibility, including an employer that does not initially qualify for the cap. · · · · · I have read and understand the rules of the 100-percent EM Cap. I understand BWC will remove the cap from the policy year beginning July 1, 2011, if I do not complete the required steps of the 10-Step Business Plan for Safety. The first year steps one, two, six and two additional steps must be completed per rule 4123-17-70 of the Ohio BWC Administrative Code. Completed documentation is due by March 31, 2012. Please indicate who you will work with to ensure compliance with the requirements to receive the 100-percent EM Cap. BWC representative BWC-certified, 10-Step Business Plan for Safety sponsor. Name: Note: A list of BWC-certified, 10-Step Business Plan for Safety sponsors are available on our Web site, ohiobwc.com. I do not wish to participate in the 100-percent EM Cap for the policy year beginning July 1, 2011. Officer/partner/owner Officer/partner/owner signature Title Date BWC-7521 (4/06/2011) PC U-18 American LegalNet, Inc. www.FormsWorkFlow.com
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