Form U 117 PDF Details

In an evolving business landscape, maintaining the accuracy of workers' compensation policy information is crucial for employers. The Notification of Policy Update, widely recognized by its form number U-117, serves as a vital tool for businesses in Ohio to communicate changes in their operational details to the Bureau of Workers' Compensation (BWC). This form encompasses diverse sections designed for specific updates, such as changes in business information, address or contact shifts, and modifications in coverage options. Employers have the flexibility to update their legal business names, trade names, entity types, and owner or officer details, ensuring that the BWC has the most current information. Furthermore, the U-117 form facilitates the cancellation of elective coverages, including the Notice of Election to Obtain Coverage from Other States for employees working outside of Ohio, without altering the primary policy number or the responsibility for premiums. This streamlined approach denotes the BWC's commitment to adaptability and efficiency, allowing employers to manage their coverage with ease. Importantly, the form also outlines the categories of individuals that qualify for elective coverage, offering a broad spectrum of options for sole proprietors, corporate officers of family farms, and partners, among others. The procedural steps for submission, including a mandatory signature for processing, underline the form's function as a comprehensive resource for Ohio's employers navigating the intricacies of workers' compensation coverage.

QuestionAnswer
Form NameForm U 117
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesbwc form u 117, bwc u 117, bwc u ohio, bwc ohio

Form Preview Example

Notification of Policy Update

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 BWC’s Web site at www.bwc.ohio.gov.

Purpose of form: To notify BWC of changes to the information on your Ohio workers’ compensation policy. Complete all sections of this form that apply to your updates. The sections are:

Section A - Update business information

(legal business name, trade name (DBA), entity type and/or owners/officers);

Section B - Update address and contact information;

Section C - Request to cancel elective coverage;

Section D - Request to cancel Ohio workers’ compensation coverage;

Section E - Request to cancel Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio (U-131).

Your assigned workers’ compensation policy number and responsibility for premium will not change as a result of completing the Notification of Policy Update (U-117). BWC will not issue a new policy number in situations where essentially the same employer, regardless of entity type, has an existing BWC policy (i.e., only one policy is established for any given individual, group of individuals or legal entity).

Coverage for certain owners or ministers is voluntary. Listed below are the categories of individuals that qualify for elective coverage. If you wish to elect coverage on a qualifying individual, you must complete and submit an Application for Elective Coverage (U3-S), which is available at www.bwc.ohio.gov or by calling 1-800-644-6292.

• Sole proprietor

• Family farm corporate officers

• Partnership

• Ordained or associate minister of a religious organization

• Limited liability company acting as a sole proprietor

• Individual incorporated as a corporation (with no employees)

• Limited liability company acting as a partnership

 

This form is not intended for situations where the employer succeeds, in whole or in part, another employer in the operation of a business. Complete Application for Ohio Workers’ Compensation coverage (U-3) if you are a new/successor employer.

Notify BWC by following these steps.

1 Complete all sections of the form that apply to your policy updates.

2Sign and date the application. BWC cannot process this form without a signature.

3 Mail the completed form to: Ohio Bureau of Workers’ Compensation

Policy Processing, 22nd floor 30 W. Spring St.

Columbus, Ohio 43215-2256

4 Fax completed form to:

Policy Processing 614-719-5313

BWC-7623 (Rev. Aug. 18, 2016)

 

U-117

Provide your policy number, federal identification number or Social Security number and legal business name as it exists on your current policy. Provide your updated information in the appropriate section of this form.

PREVIOUS federal employer identification number or Social Security number

Policy number

 

 

PREVIOUS legal business name

 

 

 

SECTION A New/update business information

You can request an update to the legal business name, trade name or doing business as (DBA), federal employer identification/Social Security number, entity type and/or owners/officers on a workers’ compensation policy when the employer is essentially the same employer (same or similar ownership group).

Update business name and/or federal employer

Effective date

identification number or Social Security number

 

 

 

New legal business name

 

 

 

New trade name or DBA

New federal employer identification number or Social Security number

 

 

Update business entity type

Please check the one business entity type below that applies to you and attach supporting documentation (e.g., certificate from Secretary of State and related materials, legal contract, etc.).

 

 

Sole proprietor

 

Limited liability company acting as a sole proprietor

 

Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Partnership

 

 

Limited liability company acting as a partnership

 

Individual incorporated as a corporation

 

 

 

 

 

 

 

 

 

 

 

 

Limited partnership

 

 

Limited liability company acting as a corporation

 

Family farm corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incorporation date

 

 

Charter number

 

 

 

 

State where incorporated

 

 

 

 

 

 

 

Have you changed the nature of your business operation or finished products?

 

 

Yes

 

No

 

 

 

 

Explain

Provide the reason for change in legal business name.

Corporate name change

Same/similar ownership group changing legal entity type

Other

Please explain:

U-117 2 of 4

 

 

 

Policy number

 

SECTION A Update business information (continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Update owner/officer information

 

 

 

 

 

 

 

Name #1 (last, first, middle)

 

 

 

Effective date

% Ownership

 

 

 

 

 

 

 

 

Home address (street or PO Box)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

 

 

 

ZIP code

 

 

 

 

 

 

 

 

 

Social Security number

Title

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name #2 (last, first, middle)

 

 

 

Effective date

% Ownership

 

 

 

 

 

 

 

 

Home address (street or PO Box)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

 

 

 

ZIP code

 

 

 

 

 

 

 

 

 

Social Security number

Title

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name #3 (last, first, middle)

 

 

 

Effective date

% Ownership

 

 

 

 

 

 

 

 

Home address (street or PO Box)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

 

 

 

ZIP code

 

 

 

 

 

 

 

 

 

Social Security number

Title

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List names of owner(s) and/or officer(s) no longer affiliated with the business (print name).

 

Name

 

End date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION B Update address and contact information

Update primary physical location and contact information

BWC uses the primary address to assign one customer service office for all your risk-management services.

Please provide the address for your primary Ohio location best capable of handling and resolving your risk-

management issues or an out of state location if you have no physical Ohio location.

Street (Do not use P.O. box)

City

 

 

State, ZIP code

Location phone

 

 

Location fax

E-mail address

 

 

Contact name

Contact phone

 

 

Update mailing address (if different from primary physical location)

Street

City

 

 

State, ZIP code

Mailing address phone number

 

 

Mailing address fax number

E-mail address

 

 

Contact name

Contact phone

 

 

U-117 3 of 4

SECTION C Request to cancel elective coverage

Policy number

If elective coverage is no longer required for one or more qualifying individuals, cancel elective coverage for the individual listed below.

Name

Effective date of cancellation

Upon cancellation of elective coverage, BWC will NOT pay benefits for work-related injuries. You must report and pay elective coverage wages up through the end date of the elective coverage. If you choose to elect coverage for a qualifying individual in the future, you must complete and submit a U-3S. You can obtain this application by visiting BWC’s Web site at ohiobwc.com or by calling 1-800-OHIOBWC.

SECTION D Request to cancel Ohio workers’ compensation coverage

If you will continue to have employees working for you, including casual labor or part-time help, you should not

cancel your coverage. Additionally, you should not cancel your coverage if you are leasing your employees from a professional employer organization (PEO). As a client in a PEO agreement, you must maintain active workers’ compensation coverage.

If workers’ compensation is no longer required, please indicate reason and other facts about the cancellation of coverage. You should maintain coverage through the last date you have employees.

 

Out of business (closed operation): Cancel account/policy

Effective date:

 

 

 

 

Business sold: (Select one)

 

All of business sold

Effective date:

 

 

 

 

 

 

 

 

Part of business sold

Effective date:

 

Purchaser (new owner) information

 

 

 

 

 

 

 

Policy number:

 

 

Acquisition/purchase date:

 

 

Legal business name:

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

Contact name and phone number:

SECTION E Request to cancel Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio

Insurer name

State of coverage

 

Effective date

SECTION F Certification - signature required

By my signature, I certify I have the authority to notify BWC of the change, and the facts set forth on this notification form are true and correct to the best of my knowledge and belief. I am aware that any person who misrepresents, conceals facts, or makes false statements may be subject to civil, criminal and/or administrative penalties.

Signature of owner, partner, member or executive officer

 

Title

 

 

 

Print name of above signature

 

Date

 

 

 

Telephone number

 

 

BWC USE ONLY

Team number

Account examiner name

U-117 4 of 4

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