Opt Out Of .99 EM Construction Cap Program {BWC-7611}

Opt Out of .99 EM Construction Cap Please return by last business day in July Instructions Complete this application. An (*) denotes a required field. BWC cannot process incomplete applications. An officer, partner or owner must sign this application. Please retain a copy for your records and proof of successful fax transmission. You may submit the completed form in one of the ways listed below. Fax ­ 614-621-1405 Mail ­ Attention: Employer Programs Ohio Bureau of Workers' Compensation 30 W. Spring St., 22nd Floor Columbus, OH 43215-2256 BWC policy number* Legal business name* Primary physical location* City* State* ZIP code* Phone Fax Email Pursuant to Amended Substitute House Bill 15, BWC will give an eligible employer the temporary .99 EM* unless the employer decides not to participate (opts out). This .99 EM will not change the employer's actual rate. BWC will calculate the actual rate based on the employer's claims experience consistent with the calculations used for all Ohio employers. Should you decide to participate in the .99 EM Construction Cap and receive a temporary .99 EM, you must: Complete the online Safety Management Self-Assessment (SH-26) last business day in July; Be responsible to pay full premium based upon actual calculated EM for the company. I, the undersigned, do hereby agree to opt out of the .99 EM Construction Cap program. Officer/partner/owner Title Officer/partner/owner signature Date * Temporary .99 EM Construction Cap does not affect employer's rates. BWC-7611 (Rev. Sept. 16, 2015) U-108 American LegalNet, Inc. www.FormsWorkFlow.com