Are you looking for more information about the Ohio Si 7 form? This document is an important one that CPAs need to understand, so it's essential to have accurate and up-to-date knowledge of its requirements. We're here to provide you with all the details on what this form entails and how you can file it correctly. Learn more about the different aspects of the Ohio Si 7 form in this blog post - from understanding which businesses must submit it, to receiving tips for filing away specific data points easily.
Question | Answer |
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Form Name | Ohio Si 7 Form |
Form Length | 8 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 2 min |
Other names | ohio si 7, ohio si7 form, si7 form ohio, ohio si 7 form |
Application for Renewal of Authorization to Operate as a
(as outlined in Ohio Revised Code Section 4123)
Renewal date
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
Company information
Employer name (shown exactly as it is in the Articles of Incorporation) |
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Federal ID number |
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Address |
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Number of Ohio employees |
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as of application date |
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(including subsidiaries) |
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City |
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County |
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State |
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Corporate contact person |
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Corporate phone number |
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Corporate FAX number |
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Corporate contact email |
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State of incorporation |
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Date of incorporation |
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Type of entity (check appropriate box) |
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n Corporation |
n Partnership |
n LLC |
n Public employer* |
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*If you checked the public employer box, please answer the questions below: |
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What was the |
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Has the |
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n No |
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Has the |
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Has the |
5. What were the unvoted debt capacities for the
Are you currently administering an approved Qualiied Health Plan or
n QHP |
n |
Ultimate USA parent information
Name of ultimate USA parent (show exactly as it is in the Articles of Incorporation) |
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Ultimate USA parent federal ID number |
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State of incorporation |
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Date of incorporation |
Percentage of ownership |
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% |
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Are inancials public?* |
* If you answered yes to are financials public, BWC can obtain your inancials directly from your |
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n Yes n No |
website or the SEC. |
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Subsidiary information
Please list subsidiary entities in Ohio, authorized by BWC to operate under this
Organization name |
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Employer federal ID number |
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Percent of ownership |
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Employee count |
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1 | Page |
Subsidiary information
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Organization name |
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Employer federal ID number |
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Percent of ownership |
Employee count |
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2 | Page |
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
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 |
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Email address |
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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 _________________________________________________________________
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: $ ______________________________________________
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Certification |
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(Notary seal) |
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State of ______________________ County of _________________________ ss _______________________________ being duly sworn says that he/she |
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is the ____________________________ of ____________________________ , the employer referred to in the foregoing is true to the best of their knowledge. |
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Sworn to before me, this ________ day of ______________________ , 20_______ . |
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Notary signature |
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Corporate oficer signature |
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3 | Page |
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Claim File Housing Locations |
Instructions |
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• Indicate all locations where you maintain claims records for auditing |
Company: ______________________________________ |
purposes (including authorized reps). |
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? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
4 | Page |
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
5 | Page |
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
6 | Page |
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Subsidiary Update Request |
Instructions |
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• List all approved subsidiary entities, including address, |
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contact, phone and email information. |
Company: _________________________________________ |
This form completed by
Name and title
Telephone number
( )
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Subsidiary name: _________________________________________ |
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Attention:_________________________________________________ |
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Telephone number: _______________________________________ |
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Address:__________________________________________________ |
The existing subsidiary has been |
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Closed |
Sold |
__________________________________________________________ |
Check if there are no changes |
Email address: ____________________________________________ |
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Subsidiary name: _________________________________________ |
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Attention:_________________________________________________ |
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Telephone number: _______________________________________ |
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Address:__________________________________________________ |
The existing subsidiary has been |
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Closed |
Sold |
__________________________________________________________ |
Check if there are no changes |
Email address: ____________________________________________ |
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Subsidiary name: _________________________________________ |
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Attention:_________________________________________________ |
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Telephone number: _______________________________________ |
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Address:__________________________________________________ |
The existing subsidiary has been |
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Closed |
Sold |
__________________________________________________________ |
Check if there are no changes |
Email address: ____________________________________________ |
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7 | Page |
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Subsidiary name: _________________________________________ |
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Attention:_________________________________________________ |
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Telephone number: _______________________________________ |
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Address:__________________________________________________ |
The existing subsidiary has been |
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Closed |
Sold |
__________________________________________________________ |
Check if there are no changes |
Email address: ____________________________________________ |
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Subsidiary name: _________________________________________ |
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Attention:_________________________________________________ |
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Telephone number: _______________________________________ |
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Address:__________________________________________________ |
The existing subsidiary has been |
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Closed |
Sold |
__________________________________________________________ |
Check if there are no changes |
Email address: ____________________________________________ |
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Subsidiary name: _________________________________________ |
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Attention:_________________________________________________ |
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Telephone number: _______________________________________ |
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Address:__________________________________________________ |
The existing subsidiary has been |
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Closed |
Sold |
__________________________________________________________ |
Check if there are no changes |
Email address: ____________________________________________ |
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Subsidiary name: _________________________________________ |
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Attention:_________________________________________________ |
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Telephone number: _______________________________________ |
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Address:__________________________________________________ |
The existing subsidiary has been |
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Closed |
Sold |
__________________________________________________________ |
Check if there are no changes |
Email address: ____________________________________________ |
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8 | Page |