Amended True-Up Payroll Report{BWC-7578}

Amended True-Up Payroll Report Instructions You must complete this form in its entirety along with a reason for the change. If supplemental coverage applies (sole proprietor, partnership, limited liability company acting as a sole proprietor/partnership, family farm corporate officer or ministers), you must report the payroll under the correct National Council on Compensation Insurance (NCCI) classification and manual type code (SN). Submit this report by fax to 614-719-5313. Policy number Legal business name Mailing address City Trading name or doing business as name Email address State Telephone number ( ZIP code ) Payroll period from through NCCI manual classification Number of employees Original reported payroll Actual payroll Manual Type code Description $ $ $ $ $ $ $ $ Reason for change $ $ $ $ $ $ $ $ Certification I hereby certify the amended payroll reported herein is correct as to the classification and amount for the period stated. I understand that misrepresentation of payroll for premium purposes could lead to a penalty of 10 times the amount of the premium underreported, as provided by Section 4123.25 of the Ohio Revised Code. By my signature, I certify I have the authority to execute this document, and that the facts set forth on this document are true and correct to the best of my knowledge and belief. I am aware that any person who does not secure or maintain workers' compensation coverage and pay all appropriate premiums in accordance with Ohio laws, or misrepresents, conceals facts or makes false statements to obtain coverage may be subject to civil, criminal and/or administrative penalties. Signature and title (must be signed by owner, partner or officer) Date BWC-7578 (Rev. Oct. 6, 2016) RPS-Amend P/R American LegalNet, Inc. www.FormsWorkFlow.com