Agreement Between Employer And The Ohio Bureau Of Workers Compensation Regarding Amount Of Self Insured Buyout {BWC-7216} | Pdf Fpdf Doc Docx | Ohio

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Agreement Between Employer And The Ohio Bureau Of Workers Compensation Regarding Amount Of Self Insured Buyout {BWC-7216} | Pdf Fpdf Doc Docx | Ohio

Agreement Between Employer And The Ohio Bureau Of Workers Compensation Regarding Amount Of Self Insured Buyout {BWC-7216}

This is a Ohio form that can be used for Employers within Workers Comp.

Alternate TextLast updated: 9/18/2006

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<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AGREEMENT BETWEEN EMPLOYER AND:::::::THE OHIO BUREAU OF WORKERS' COMPENSATION REGARDING AMOUNT OF SELF-INSURED BUYOUTIndex No.Better Workers' CompensationBuilt with you in mind.Calendar No.(hereinafter"employer"),anemployer doing business in the State of Ohio and having its principal offices of authorized agent at , Ohio, in consideration of the Ohio Bureau of Workers' Compensation granting the privilege of self-insuring its liabilities arising under Chapter 4123 of the Ohio Revised Code, voluntarily and knowingly executes this Agreement with the express intention of being legally bound and effecting the obligations herein described for itself, its assigns and successors in interest.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)1. Both parties covenant that this Agreement is a full and complete statement of the matters contained herein, extinguishingand making null and void any and all prior and contemporaneous agreements.2. The employer hereby agrees to pay within thirty (30) calendar days of notification by the Ohio Bureau of Workers'Compensation of approval of self-insurance the sum of dollars in cash or certified check, payable to Bureau of Workers' Compensation as the proper amount specified in Rule 4123-19-03 (M) of the Ohio Bureau of Workers' Compensation for the employer's proportionate share of any deficit in the State Insurance Fund. The employer's liability shall be determined by applying factors, determined by the actuary of the Bureau, to pure premium paidbytheemployerbasedupongrosspayrollforasevenyearperiod. Thetimelyandproperpaymentinfullofthebuyout amount shall be an express condition precedent of the privilege of self-insurance by the employer.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. The employer hereby agrees to pay the Ohio Bureau of Workers' Compensation for any amounts determined to be dueTHE PEOPLE OF THE STATE OF NEW YORK TOand owing under Revised Code §4123.411(C), whether arising out of State Fund or Self-Insured claims.4. Both parties hereby agree that the sum contained in paragraph two (2) shall be the complete and total amount of thebuyout, subject solely to the following adjustments:A. Futureincreasesordecreasesbaseduponprotestletters,applicationsforhandicapreimbursementorotherrequestsexpressly set forth herein which the employer, its assigns and successors in interest has actual or constructive knowledge, filed with the Ohio Bureau of Workers' Compensation prior to this Agreement. The employer expressly agrees that any protest letters, applications for handicap reimbursement, or other requests effecting the employer's State Fund risk experience filed subsequent to this Agreement shall be considered invalid for both rebate of premium on State Fund experience and for calculation of the buyout amount as described in Rule 4123-19-03 (M) of the rules of the Ohio Bureau of Workers' Compensation.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofThe following constitutes a full and complete listing of all such outstanding applications, letters, and claims known to the employer:o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.The following consists of adjustments as proposed by the Ohio Bureau of Workers' Compensation., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)B. The final adjustments of all premiums due the State Fund for the final payroll reports and final Bureau audit asprovided for in Rule 4123-19-03 (N) (5), Rules of the Ohio Bureau of Workers' Compensation.5. The employer agrees that any billings made by the Ohio Bureau of Workers' Compensation in accordance with paragraphfour (4) of this Agreement, shall be paid within fifteen (15) calendar days of billing.Attorney(s) for6. Theemployer,itsassignsandsuccessorsininterestexpresslywaivesforeveranyclaimsforpremiumorlossadjustmentsnot expressly contained in this Agreement. The employer, its assigns and successors in interest also expressly waives its claim to any future rebates or dividends from the State Insurance Fund for state fund employers payable after the effective date of the employer's self-insurance.Office and P.O. Address7. Bothpartiesagreethatanyambiguityinconnectionwiththeinterpretationorexecutionofthisagreementshallberesolvedin accordance with Rule 4123-19-03, rules of the Ohio Bureau of Workers' Compensation, and other pertinent rules as set forth by the Ohio Bureau of Workers' Compensation as of the date of this Agreement.Telephone No.: Facsimile No.: E-Mail Address:Entered into this day of , at by , authorized agent for this employer. BWC-7216 (Rev. 8/20/1999) SI-16Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com</document>

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