Sponsor Certification Application {BWC-7655}

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