Self-Insured Construction Project Application {BWC-7250}

Self-Insured Construction Wrap-Up Application Instructions Please answer all questions. If not applicable, use symbol with N/A. Submit completed applications to the: Ohio Bureau of Workers' Compensation, nd Attn: Self-Insured Department ­ 22 Floor, Columbus, OH 43215. You can also submit an application via email to SIINQ@bwc.state.oh.us. BWC must receive applications 90 days prior to the desired effective date. 1. Self-insured employer Policy name Policy address Policy phone Policy federal ID number Policy number 2000______________________________ 2. Project description (Please attach a detailed scope of this project.) Project name Scheduled project start date Address Enter description of project here Estimated cost of the project Scheduled project completion date 3. Project administration Project administrator (company) name Project administrator address Project administrator phone Describe claims administration plan and claims reporting process Statement addressing whether there is a collective bargaining agreement between the self-insured employer and labor organization. Project administrator e-mail 4. Contractor/Subcontractor information Name/Address of contractor and subcontractors to be covered under the wrap-up program. (Note: If complete list of contractors is not known at the time of application, you must submit this information prior to the project start date. Per ORC 4123.35 (O)(2) and OAC 4123.19.16 (E)(3), the self-insuring employer must notify BWC timely when a contractor or subcontractor is added or removed from a project). Name of contractor and sub contractor Address of contractor and subcontractor BWC-7250 SI-50 American LegalNet, Inc. www.FormsWorkFlow.com Is the self-insured employer acting as the general contractor or construction manager? Will wrap-up program cover all employees on the job site? Yes No If no, which employees will the program exclude and how will you accomplish that? Describe the method in which you will compile and track the payroll for all contractors and subcontractors to show a clear audit trail. 5. Safety plan Name of safety professional responsible for administration and enforcement of the safety program for the project: Attach safety program specifically designed for the construction project (Complies with OSHA standards and provides for management and employee involvement). 6. Certification State County of (title) of being duly sworn says that he/she is the (employer name), the employer referred to In the forgoing statements and all of the foregoing statements are true to the best of his/her knowledge. Sworn to me, this day of Corporate officer Title Notary Seal BWC-7250 SI-50 American LegalNet, Inc. www.FormsWorkFlow.com