Form Preview Example

Organization name

Employer federal ID number

Percent of ownership

Employee count

Application for Renewal of Authorization to Operate as a Self-insured Policy

(as outlined in Ohio Revised Code Section 4123)

Renewal date

Self-insured policy number

Instructions

•Please answer all questions. If not applicable, use symbol N/A.

•You must ile all requests for data and inancial statements, or BWC will not consider renewal of self-insurance.

Company information

Employer name (shown exactly as it is in the Articles of Incorporation)									Federal ID number

Address									Number of Ohio employees
									as of application date
									(including subsidiaries)

City				County				State	Nine-digit ZIP Code

Corporate contact person						Corporate phone number			Corporate FAX number
						(	)		(	)

Corporate contact email						State of incorporation			Date of incorporation

Type of entity (check appropriate box)
n Corporation		n Partnership	n LLC		n Public employer*
*If you checked the public employer box, please answer the questions below:
1.	What was the self-insured applicant’s bond rating at the end of the most recent iscal year? __________________________
2.	Has the self-insured applicant complied with all SEC disclosures for the last ive years? n Yes									n No
3.	Has the self-insured applicant had any local government fund distributions withheld in the last ive years? n Yes n No
4.	Has the self-insured applicant been placed on iscal watch or emergency in the last ive years? n Yes n No

5. What were the unvoted debt capacities for the self-insured applicant for the end of the two most recent iscal years? Current year $ __________________________ Prior year $ __________________________

Are you currently administering an approved Qualiied Health Plan or Medical-Management Plan?

n QHP

n Medical-Management Plan

Ultimate USA parent information

Name of ultimate USA parent (show exactly as it is in the Articles of Incorporation)			Ultimate USA parent federal ID number

State of incorporation		Date of incorporation		Percentage of ownership
				%

Are inancials public?*	* If you answered yes to are ﬁnancials public, BWC can obtain your inancials directly from your
n Yes n No	website or the SEC.
n Yes n No

Subsidiary information

Please list subsidiary entities in Ohio, authorized by BWC to operate under this self-insured policy number. Authorized subsidiaries are listed on the Certiﬁcate of Employer's Right to Pay Compensation Directly. If an entity does not appear on your certiﬁcate, you must ﬁle an initial application for self-insurance with the self-insured department.

BWC-7207 (Rev. 2/21/2013)

1 | Page

SI-7

Subsidiary information

Organization name	Employer federal ID number	Percent of ownership	Employee count

BWC-7207 (Rev. 2/21/2013)

2 | Page

SI-7

Ohio administrator’s phone number

( )

Corporate restructuring

Please note: For BWC to properly process the referenced revisions, please provide Ohio secretary of state papers and updated organizational chart.

Has your corporate name, structure or ultimate U.S. parent changed during the past year?

n Yes n No

If yes, please provide detailed explanation: ____________________________________________________________________________________________

Ohio administrator information

Note:This administrator must be an employee of your company. It cannot be yourTPA.

Has your Ohio administrator changed in the last 12 months? n Yes n No

Does the Ohio administrator have one or more years of experience as a workers' compensation administrator for self-insured employers in Ohio? n Yes n No

Ohio administrator's name

Ohio administrator’s fax number

( )

Ohio administrator’s email address

Authorized representative

Has the authorized representative changed in the last 12 months? n Yes n No

Representative name

Representative identiication number	Representative phone number
	(	)
Email address

Excess workers' compensation insurance

Does your company carry excess workers' compensation insurance?* n Yes n No

*If you answered yes to does your company carry excess workers' compensation insurance, please submit a copy of the policies declaration page to SIINQ@bwc.state.oh.us

Name of carrier: _____________________________________________________________________________________________________________________

Name of agent: ______________________________________________________Telephone number: (________)____________________________________

Policy number: _______________________________________________________________________________________________________________________

Current policy period: From ______________________________________ to _________________________________________________________________

Self-insured retention: ________________________________________________________________________________________________________________

Is excess insurance paying claims?*

n Yes n No *If yes, please submit claim number(s) on a separate document to siinq@bwc.state.oh.us

Ohio assets and gross payroll information

Calendar and/or iscal year ending __________/__________/__________

MM DD YYYY

Ohio assets: $ ____________________________________________________

Ohio gross payroll: $ ______________________________________________

		Certiﬁcation
	(Notary seal)
	State of ______________________ County of _________________________ ss _______________________________ being duly sworn says that he/she
	is the ____________________________ of ____________________________ , the employer referred to in the foregoing is true to the best of their knowledge.
	Sworn to before me, this ________ day of ______________________ , 20_______ .

	Notary signature		Corporate oficer signature

BWC-7207 (Rev. 2/21/2013)			3 \| Page

SI-7

	Claim File Housing Locations
Instructions	Self-insured policy number: ______________________
• Indicate all locations where you maintain claims records for auditing	Company: ______________________________________
purposes (including authorized reps).	Company: ______________________________________

This form completed by

Name and title

Telephone number

( )

Company/authorized representative: _________________________________________________________________________

Contact name: ______________________________________________________________________________________________

Telephone number: __________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Email address: _________________________________________________________________________________________________

Date range of claims: _________________________________________________________________________________________

Approximate number of claims housed in this location? _______________________________________________________