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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 4/7/2011
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Sponsor Certification Application ·Completethisapplication. ·Attacheachoftherequesteditemstotheapplication. ·IfyouwereapprovedasaBWC-certifiedsponsorin2009orlater,andyouareapplyingforrecertification, youonlyneedtoprovidetheinformationdesignatedwitha"*"duringtherecertificationprocess. ·Sendformto:EmployerPrograms,22ndFloor,OhioBureauofWorkers'Compensation, 30W.SpringSt.,Columbus,OH43215-2256. Instructions General Information Legalbusinessname*Policynumber* Address*City*State* IPcode* Z Contactperson* E-mail* Totalnumberofmembers* Totalnumberofmembersnotingroup* Phone* Fax* otalnumberofmembersingroup* T AreyourequiredtofileanIRS990form?* es Y No Nameofthird-partyadministrator(ifapplicable)* Please use the check list below to ensure you include the items with the certification application. Signedsponsorcertificationapplicationform* Proofofactiveworkerscompensationcoverage(BWCCertificate) Articlesofincorporation Certificationsafetyagreementforsponsorsandaffiliatesponsors* Missionstatement Marketingmaterial(thisincludesadescriptionofservicesrelatedtogroupaswellasotherservices, brochures,Webinformation,newslettersandothermaterialthatallowsBWCtobetterunderstandthefocus oftheorganization). SignedSponsor Certification Application(U-149)andallcertificationcomponentslistedintheU-149foreach sponsoringaffiliate.(Anaffiliatedorganizationisanorganizationinwhichmembersarebrokered,borrowed, shared,orco-optedforinclusioninthecertifiedsponsoringorganization'sgroup.)* Insigningbelow,IherebycertifymyorganizationisapplyingtobecomeaBWC-certifiedsponsorfortheGroup-Retro and/orGroup-RatingProgram.IfurtherunderstandImaybesubjecttocivil,criminaland/oradministrativepenalties astheresultofanyfalseormisleadingstatement(s)madeinconjunctionwiththisapplication. Name Signature Title Date X BWC-7655(Rev.2/17/2011) U-149 American LegalNet, Inc. www.FormsWorkFlow.com
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