Ohio > Workers Comp > Employers

Sponsor Certification Application BWC-7655 - Ohio

Sponsor Certification Application Form. This is a Ohio form and can be used in Employers Workers Comp .
 Fillable pdf Last Modified 2/25/2015
Get this form for FREE as a print-only pdf

Sponsor Certification Application Instructions · Completethisapplication. · ttacheachoftherequesteditemstotheapplication. A · IfyouwereapprovedasaBWC-certifiedsponsorin2009orlater,andyouareapplyingforrecertification,youonlyneedto providetheinformationdesignatedwitha"*"duringtherecertificationprocess. · Sendformto:EmployerPrograms,22ndFloor,OhioBureauofWorkers'Compensation, · 30W.SpringSt.,Columbus,OH43215-2256. General Information Legalbusinessname*Policynumber* Address*City*State* IPcode* Z Contactperson* E-mail* Totalnumberofmembers* Totalnumberofmembersnotingroup* Phone* Fax* otalnumberofmembersingroup* T AreyourequiredtofileanIRS990form?* es Y Nameofthird-partyadministrator(ifapplicable)* No Please use the check list below to ensure you include the items with the certification application. SignedSponsor Certification Application(U-149)andallcertificationcomponentslistedintheU-149foreach sponsoringaffiliate.(Anaffiliatedorganizationisanorganizationinwhichmembersarebrokered,borrowed, shared,orco-optedforinclusioninthecertifiedsponsoringorganization'sgroup.)* Proofofactiveworkerscompensationcoverage(BWCCertificate) Articlesofincorporation Certificationsafetyagreementforsponsorsandaffiliatesponsors* Missionstatement Marketingmaterial(thisincludesadescriptionofservicesrelatedtogroupaswellasotherservices, brochures,Webinformation,newslettersandothermaterialthatallowsBWCtobetterunderstandthefocus oftheorganization). Insigningbelow,IherebycertifymyorganizationisapplyingtobecomeaBWC-certifiedsponsorfortheGroup-Retro and/orGroup-RatingProgram.IfurtherunderstandImaybesubjecttocivil,criminaland/oradministrativepenalties astheresultofanyfalseormisleadingstatement(s)madeinconjunctionwiththisapplication. Name Signature Title Date X BWC-7655(Rev.April13,2016) U-149 American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. Guardianship
  2. JUDGMENT
  3. power of attorney
  4. answer to complaint
  5. default judgment
  6. complaint
  7. child support
  8. writ
  9. certificate of service
  10. motion to dismiss

Bookmark and Share