Bwc 7503 Application Form – Fill Out and Use This PDF

Application for

Ohio Workers’ Compensation Coverage

Have question? Need assistance? BWC is here to help!

Call 1-800-644-6292, and listen to the options to reach a customer service representative.

You can dial the number nationwide, and in Canada and Mexico from 7:30 a.m. to 5:30 p.m. EST.

Remember, you can access information and request services by visiting BWC’s website at www.bwc.ohio.gov.

Ohio law requires employers to obtain workers’ compensation coverage for their employees from the first date of hire. Indicate the date your employees first earned wages in Ohio or the date you estimate your employees will first earn wages in Ohio. If you do not provide this information, you may be assessed a penalty for non-covered periods where coverage should have been obtained.

Be sure to supply your federal employer identification number (FEIN).You can obtain a FEIN number by calling the Internal Revenue Service. If you have applied for a FEIN, but have not received one, write “applied for” in the appropriate box, and you may supply it at a later date. Domestic household employers, sole proprietors and partnerships who do not need a FEIN should supply a Social Security number of the sole proprietor, one of the home owners or partners.

Address information

BWC uses your primary physical Ohio location to assign one customer service office for all your policy services. Please provide the address for your primary Ohio location best capable of handling and resolving your policy issues or an out of state location if you have no physical Ohio location. BWC will send all employer related correspondence including your policy invoice to the mailing address. If no mailing address is provided, BWC will use the primary physical Ohio location for all employer notifications.

Coverage is not in effect until BWC receives the completed application and the $120 non-refundable application fee. In addition, coverage should be contingent on the timely receipt of the first installment payment. BWC cannot process incomplete applications.

BWC-7503 (Rev. Nov. 20, 2015)

Instruction page 1 of 4

U-3

Additional Ohio locations

This section is used for additional Ohio locations that may be covered under this policy. Please provide a brief description of operation for each location.

Business information

Please provide general business information for your primary location.

Business contact information

Provide specific individual(s) information that will allow BWC to make direct contact with those handling your workers’ compensation matters.

Domestic household coverage

Coverage applies to full or part-time domestic workers employed inside or outside your private residence and includes private chauffeurs. Domestic household employers who pay workers $160 or more in a calendar quarter must have workers’ compensation insurance. Normally these workers provide domestic services such as gardening, housekeeping, babysitting, etc. However, you should include workers you hire as employees to provide home improvement for construction type activities to your residence if the worker does not have his or her own business or their own workers’ compensation insurance. Please check the appropriate box under Domestic household employer that applies to the type of worker you will hire, and supply a 12-month estimate so BWC may calculate your future installment payments due. If you are hiring a contractor to perform these services, you may want to verify he or she has active workers’ compensation coverage.

Business entity information

Select the one business entity type that applies to your company. For workers’ compensation purposes, there are four possible business entity types that apply to a corporation (i.e., limited liability company acting as a corporation, corporation, individual incorporated as a corporation with no employees and family farm corporation). Select the business entity type that best describes your corporate structure. Be sure to include the corporation date, charter number and state where incorporated. If incorporated in a state other than Ohio, the charter number may be referred to as some other identifier name.

Sole proprietor and partners (including limited liability companies acting as a sole proprietor or partnership): Sole proprietor and partners are exempt from workers’ compensation coverage. However, you must cover your employees. If you qualify for elective coverage, you can elect coverage by selecting Yes in the elective coverage section and the owners/officers/minister information section of this application.

Limited liability companies: These companies can elect to be treated as a corporation, sole proprietorship or partnership for income tax purposes. Because of this, owners of a limited liability company can be treated differently depending upon the form of entity they elect for income tax purposes. Therefore, if you file your income taxes as a sole proprietorship or partnership, coverage is elective for the owners. If you file your income taxes as a corporation, coverage for the owners is not elective except for an individual incorporated as a corporation (with no employees).

Corporations: Corporate officer reportable wages are subject to a minimum and maximum amount based on the statewide average weekly wage and the effective date of the policy period.The minimum reportable payroll applies only to active executive officers of the corporation (i.e., officers engaged in the decision making and the day to day operation of the corporation). Officers of a corporation who earn between the minimum and maximum will report their actual W-2 wages. For S-corporations, officers must report wages for services they perform.This may include W-2 wages as well as all or part of ordinary income from Schedule K-1 up to the maximum. Officers of a nonprofit corporation, as defined in section 1701.02 of the Ohio revised code, who volunteers the person’s services as an officer are excluded from workers’ compensation coverage.

Note: Log on to www.bwc.ohio.gov and click on the Employers section. From the left-side menu go to Payroll/Premium, then select Payroll true-up reports, then select Details, then select Minimum and maximum payroll reporting requirements to obtain the minimum and maximum payroll reporting requirement amounts applicable for the policy year.

Individuals incorporated as a corporation (with no employees): To qualify for this business entity type you must have a single/ sole owner with no employees. The single/sole owner with no employees can elect coverage by selecting “Yes” in the elective coverage section and the ownership/officers/ministers information section of this application. By law, corporations having more than one owner or a single/sole owner with employees must have workers’ compensation coverage for all personnel associated with the corporation, including all corporate officers.

Family farm corporation: These officers are exempt from workers’ compensation coverage. However, they must cover their employees. These family farm corporate officers can elect coverage by selecting “Yes” in the elective coverage section and in the owners/officers/minister information section of this application. To qualify as a family farm corporation, you must meet the following criteria:

•The family farm must be founded for the purpose of farming animal or plant products intended for consumption by human beings or animals (excluding nurseries and flower production enterprises);

•A majority of the shareholders must be related within the fourth degree of kinship (siblings, parents, grandparents, aunts, uncles, great aunts, great uncles, or first cousins) or be the spouse of such persons;

•No shareholder may be a corporation;

•At least one of the related persons within the corporation must reside on or actively operate the farm.

Association: In general, an association is a group of persons banded together for a specific purpose. To qualify under section 501(a) of the Code, the association must have a written document such as articles of association showing its creation. At least two persons must sign and date the document.

Retain for your records

Instruction page 2 of 4

Elective coverage

Coverage on certain owners or ministers is elective.The categories of individuals that qualify for elective coverage are listed below.

•Sole Proprietor

•Partnership

•Limited liability company acting as a sole proprietor

•Limited liability company acting as partnership

•Family farm corporate officers

•Ordained or associate ministers of a religious organization in the exercise of their ministries

•Individual incorporated as a corporation (with no employees)

If you qualify for elective coverage, you can elect coverage by selectingYes in the Elective coverage section and the owners/officers/ ministers information section of this application. If you choose not to cover yourself at this time, you may elect coverage at a later date time and/or to add additional qualifying owners or ministers by completing the Application for Elective Coverage (U3S). Remember, if you choose not to cover yourself and you are injured at work, BWC will not provide coverage and other insurance may not cover your work-related disability or medical bills.

Specific payroll reporting requirements associated with elective coverage are listed below.

Sole proprietors and partners (including limited liability companies acting as a sole proprietor or partnership): For all individuals electing coverage, the reportable wages are subject to a minimum and maximum amount based on the statewide average weekly wage.The minimum and maximum reporting requirements are determined by the effective date of the policy period. To determine the current minimum and maximum reporting requirements refer to the note below. Individuals who earn between the minimum and maximum must report their actual net incomes based on their federal tax form Schedule C for sole proprietors or Schedule K-1 for partnerships, inclusive of any draws.

Officers of a family farm corporation: For corporate officers of a family farm electing coverage, the reportable wages are subject to a minimum and maximum amount based on the statewide average weekly wage.The minimum and maximum reporting requirements are determined by the effective date of the policy period.To determine the current minimum and maximum reporting requirements refer to the note below. Corporate officers of a family farm who earn between the minimum and maximum must report their actual W-2 wages for corporations or S-corporations. Officers must report a reasonable wage for services they perform, including W-2 wages. Wages include all or part of the ordinary income from Schedule K-1.

Religious organizations: Ohio law requires religious organizations to cover their paid employees. However, ordained ministers and associate ministers are not considered employees for the purpose of workers’ compensation. When a minister is covered under the religious organization’s policy they must report actual earnings, which are not subject to the minimum and maximum. However, a minister who elects coverage as a sole proprietor is subject to the minimum and maximum amount based on the statewide average weekly wage and the effective date of the policy period.

Individuals incorporated as a corporation (with no employees): Individuals electing coverage must report actual wages subject to a minimum and maximum amount based on the statewide average weekly wage and the effective date of the policy period.To determine the current minimum and maximum reporting requirements refer to the note below. ICORP owners who earn between the minimum and maximum must report their actual wages. ICORP owners must report a reasonable wage for services they perform, including W-2 wages. Wages include all or part of the ordinary income from Schedule K-1.

Note: Log on to www.bwc.ohio.gov and click on the Employers section. From the left-side menu go to Payroll/Premium, then select Payroll true-up reports, then select Details, then select Minimum and maximum payroll reporting requirements to obtain the minimum and maximum payroll reporting requirement amounts applicable for the policy year.

Owners/officers/ministers information (does not apply to domestic household employers)

You must provide name, home address, Social Security number, date of birth, title/relationship and percentage of ownership interest, if any. If contact information is different than that provided in the business or business contact information section, you may provide that information here. Provide a brief description of your duties as an owner/officer/minister. (Attach additional sheets, if necessary). Additionally, individuals that qualify for elective coverage must indicate whether or not they wish to elect coverage for themselves in this section.

Operations description (does not apply to domestic household employers)

A complete description of your business is necessary to classify your operations. If you supply inadequate information, BWC could misclassify your policy. To prevent this from occurring, BWC asks that you supply in-depth information regarding your processes, the equipment used and any final product you may produce.

Retain for your records

Instruction page 3 of 4

Out-of-state considerations

Ohio employers: You must disclose payroll information for employees who are from Ohio but work within and outside of Ohio. However, you may segregate your payroll by state if you elect to obtain non-BWC coverage for work done outside of Ohio. Please refer to BWC’s Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio (U-131) and instructions to determine if this election is available to your business.

If you elect coverage from another state, you:

•Should NOT include work done outside of Ohio when reporting payroll or calculating premium payments to BWC for work done in Ohio;

•Must report payroll for work done outside of Ohio to BWC on a separate form. (This is for recordkeeping purposes only.You do NOT have to pay an Ohio premium for out-of-state work.)

Out-of-state employers: BWC will recognize out-of-state coverage for employees who are residents of another state but work in Ohio for no more than 90 days. You must obtain coverage and report payroll to BWC only if a temporary period exceeds 90 days. Multiple temporary periods with each exposure less than 91 days in duration is a distinct temporary period.

If you specifically hire employees to work in Ohio, you must obtain coverage from BWC regardless of where you hired the workers.

Premium payment installment plan

Ohio law allows for employers who pay a premium greater than the minimum $120 to select a payment plan installment schedule. Employers who report the minimum premium will automatically be set up on a one pay.The option you select may not be available for your first policy period. If you meet the qualifications for the payment plan option you selected, the payment plan schedule will be available for your first full policy year.

Estimated annual payroll by operation type (does not apply to domestic household employers)

Provide the estimated 12-month Ohio payroll for each operation conducted by your employees as well as the number of employees you have under each operation. For individuals who qualify for elective coverage, list only those who have elected coverage in the owner/officer/minister information section. The estimated annual payroll is used to calculate your estimated annual premium which will determine your installment billings. If the estimated payroll increases or decreases significantly through the course of the policy year, please contact BWC.

Business acquisition/merger or purchase/sale and associated policy information

For all successions on or after Sept. 1, 2006, in situations where a successor takes over the entire operation, any and all existing and future liabilities will transfer to the successor in addition to the experience. Pursuant to Ohio Administrative Code 4123-17-02 you may be considered a successor if you continue the previous employer’s operations, even if there is no purchase. In such cases, it will be the successor’s responsibility to notify BWC of the succession. When you acquire or purchase a business, you must apply for Ohio workers’ compensation coverage if you have one or more employees. An exception to this would be when the operations are continued by a family member. In such case you may complete Notification of Policy Update to Make Changes to the Existing Policy (U-117).

If an employer purchases or acquires only a portion of the business, BWC transfers only that portion of the former employer’s experience to the succeeding employer. BWC will inspect the former employer’s payroll and claims records to determine what should transfer to the successor for rate calculation purposes.

Certification - Signature required

All applications require a signature. Please be sure to complete this area.

Coverage is not in effect until BWC receives the completed application and the $120 non-refundable application fee. In addition, coverage should be contingent on the timely receipt of the first installment payment. BWC cannot process incomplete applications.

Retain for your records

Instruction page 4 of 4

Application for

Ohio Workers’ Compensation Coverage

Have questions? Need assistance? BWC is here to help!

Call 1-800-644-6292, and listen to the options to reach a customer service representative.

You can dial the number nationwide, and in Canada and Mexico from 7:30 a.m. to 5:30 p.m. EST. Remember, you can access information and request services by visiting www.bwc.ohio.gov.

BWC will not process incomplete applications. You must complete all required fields (*).

BWC will also not process applications without a $120 non-refundable application fee.

General information – completed by all employer types

	*Legal business name or homeowner name		*Federal employer identification number or Social Security number
	Trade name or doing business as name		*Date employees first earned wages in Ohio. If no employees,
			enter today’s date.
	Address information
	*Primary physical (Ohio) location: If no Ohio location, provide your out-of-state location
	Street (Do not use P.O. box)	City	State	ZIP code
	*Mailing address: If different from primary (Ohio) location
	Street	City	State	ZIP code

Additional Ohio locations (attach additional sheets if necessary)

Business information (for your primary Ohio location)

*Business phone: Is this a cell  Yes or  No

Business fax

Business contact information (primary contact(s) for the business)

*Contact #1 (First, Middle initial, Last and Suffix)	*Title/Contact type
*Phone:  Direct Dial or  Cell	Email
Contact #2 (First, Middle Initial, Last and Suffix)	Title/Contact type
Phone:  Direct Dial or  Cell	Email

Domestic household coverage

Domestic household: Applies to full/part-time domestic workers employed inside or outside your private residence. Check the type of services your domestic household employees will perform within your residence.

 Domestic inside and/or outside yard/ground maintenance Home improvement/Maintenance Construction (new/addition/roofing) on or in your home. 12-month payroll estimate ______________________

Business entity information

*Please check the one business entity type below that applies to you.

 Sole proprietor	 Limited liability company acting as a sole proprietor	 Family farm corporation
 Partnership	 Limited liability company acting as a partnership	 Association
 Limited partnership	 Limited liability company acting as a corporation	 State/local government
 Corporation	 Individual incorporated as a corporation
Incorporation date	Charter number	State where incorporated
BWC-7503 (Rev. May 17, 2017)		Application Page 1 of 4
U-3

Elective coverage

See additional details in the business entity information and elective coverage sections for completing the application, which describe the reporting requirements for elective coverage.

Coverage on the owners or officers of a corporation and a limited liability company acting as a corporation (except for individuals incorporated as a corporation with no employees) are automatically covered (i.e., coverage is not voluntary).

Coverage on certain owners or ministers is voluntary. Listed below are the categories of individuals that qualify for elective coverage.

Sole proprietor

Partnership

Limited liability company acting as a sole proprietor

Limited liability company acting as a partnership

Family farm corporate officers

Ordained or associate minister of a religious organization

Individual incorporated as a corporation (with no employees)

If individuals at your company meet the qualifications for elective coverage, please enter all of their names in the owner/officers/minister information section. If you select yes to request elective coverage, please understand that by electing coverage that you are acknowledging your agreement to the minimum payroll reporting requirements outlined in the U-3 instructions. Remember, if you choose not to cover yourself and you are injured at work, BWC will not provide coverage, and other insurance may not cover your work-related disability or medical bills.

Please initial to acknowledge you have read and understand the elective coverage guidelines.

Owners/officers/ministers: Include the names of all owners and officers. If you are a religious organization you only need to provide the names of the ministers who you wish to elect coverage.

*Name #1 (First, Middle Initial, Last and Suffix)		*Social Security number	Date of birth	*Title/Relationship
*Home mailing address (street, city, state, ZIP code)					*% Ownership
*Phone:  Home or  Cell	Email
*Duties
*For individuals that qualify, do you wish to elect coverage? (see elective coverage section)
 YES I do wish to elect coverage for myself.
 NO I understand that BWC will not pay benefits for my work-related injury if I do not elect coverage
*Name #2 (First, Middle Initial, Last and Suffix)		*Social Security number	Date of birth	*Title/Relationship
*Home mailing address (street, city, state, ZIP code)					*% Ownership
*Phone:  Home or  Cell	Email
*Duties
*For individuals that qualify, do you wish to elect coverage? (see elective coverage section)
 YES I do wish to elect coverage for myself.
 NO I understand that BWC will not pay benefits for my work-related injury if I do not elect coverage
*Name #3 (First, Middle Initial, Last and Suffix)		*Social Security number	Date of birth	*Title/Relationship

*For individuals that qualify, do you wish to elect coverage? (see elective coverage section)

YES I do wish to elect coverage for myself.

NO I understand that BWC will not pay benefits for my work-related injury if I do not elect coverage

Total ownership %

BWC-7503 (Rev. May 17, 2017)

Application Page 2 of 4

U-3

Estimated annual payroll by operation type

*Operation type (List all types - attach additional sheets if necessary).	*Estimate number of	*Estimate total payroll
Provide estimated information for all employees including officers of a corporation or LLC corporation	employees.	for next twelve months.

Clerical office personnel (No duties outside the office, in sales or service, no counter service or exposure to factory operations);

Clerical telecommuter (clerical employees working from residence);

Traveling salespeople (no handling, service or delivery);

Drivers (truck or delivery).

Provide estimated information for each sole proprietor, partner, individual incorporated as a corporation, family farm corporate officer or minister that has elected coverage on themselves.

Name #1:

Name #2:

Name #3:

Business acquisition/merger or purchase/sale and associated policy information

Have there been other Ohio workers’ compensation policies associated with this					*Do any of the principals have workers’ compensation coverage in this or any other
operation or any other affiliated operation?  Yes  No					operation; or have they had workers’ compensation coverage in any operation in
					the past?  Yes  No
List policy(s) number _________________________________________________					Name ____________________________________________________________
*Did you acquire/purchase this		*Previous business name and BWC policy number			*Date you acquired/purchased business				*Did you acquire/purchase  all or
business?  Yes  No									 part of an existing business
Did you acquire/purchase this business from a family member?				Was this a stock acquisition?			 Yes  No		How many employees of the former
 Yes  No				If yes, did you retain the previous employer’s federal					employer did you hire?
If yes, indicate relationship ______________________________________				identification number?  Yes			 No
Previous employer contact name			Previous employer phone number				Do you have a purchase agreement associated with the
							transaction?  Yes	 No
							If yes, BWC may request a copy of the agreement.

Was the business purchased out of bankruptcy or receivership?  Yes  No

Explain

Has the business been in continuous operation?  Yes  No

Explain

Did you acquire/purchase the previous employer’s contracts or customers?  Yes  No

Explain

Are you operating in the former employer’s location?  Yes  No

Explain

Will you conduct business in the same/similar manner as the former employer?  Yes  No

Explain

Did you acquire or purchase any machinery or equipment from the former employer?  Yes  No

Explain

Certifications – signature required

Name (please print)

By my signature, I certify I have the authority to execute this application, and that the facts set forth on this application are true and correct to the best of my knowledge and belief. I am aware that any person who does not secure or maintain wo rkers’ 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.

*Employer signature _______________________________________________________________Title:___________________________________ *Date: ___________________________

WARNING: Insurance is not in effect until BWC receives the application and the $120 non-refundable application fee. In addition, coverage should be contingent on the timely receipt of the first installment payment.

BWC will bill the balance of the yearly premium. BWC cannot process incomplete applications or applications submitted without payment.

BWC USE ONLY

BWC-7503 (Rev. May 17, 2017)

Application Page 4 of 4

U-3