Ohio Form Ua 3 – Fill Out and Use This PDF

Professional Employer Organization

Client Relationship Notification

Instructions

∙Use this form to notify BWC of a new client, change of relationship with a current client or termination of a client.

∙Mail this form to BWC, PEO Unit, 22nd Floor, 30 W. Spring St., Columbus, OH 43215-2256, or send a fax to 614-719-5925.

∙BWC must receive new contract notification within 30 days of the effective date of the contract. BWC must receive contract termination notifications within 14 days of the effective date of the termination.

∙Notice: Pursuant to Ohio Administrative Code 4123-17-15.1(B), if BWC is not notified within the required time frame, BWC will recognize the date the UA-3 is received as the effective date.

Professional employer organization (PEO) information

Company name	Policy number
Contact person name	Telephone number

PEO lease information

	Check only one	Change existing policy number reporting client	Effective date of lease, termination or change in
	New lease
		payroll/claims	Ohio
	Lease termination	Change to portion of client’s employees assumed by PEO
		(No splitting of employees within a manual classification)

Client company information

Client company name		Client policy number
DBA		Federal ID number
Mailing address (P.O. Box if applicable)		Client phone number
City		State	Nine-digit ZIP code

Employee reporting (payroll and claims)

List class codes reportable by PEO

List class codes reportable by client

All under the PEO policy

PEO

Client

All under the client policy

A portion under the PEO policy

(Partial wages reported to BWC under the

client policy must be reported under the

FEIN of the client employer)

Print client signatory

Client signature

Print PEO signatory

PEO signature

Note: Signing this form is an acknowledgement that all the information listed on this form is complete and true to the best of your knowledge. Omission of any of the items required or intentional misrepresentation of any of the above information on this form may lead to registration revocation as outlined in Ohio Revised Code Section 4125.

BWC-8003 (May 15, 2014)

UA-3