Ohio Si 7 Form PDF Details

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.

QuestionAnswer
Form NameOhio Si 7 Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesohio si 7, ohio si7 form, si7 form ohio, ohio si 7 form

Form Preview Example

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.

 

 

 

 

 

 

 

 

 

 

 

 

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.

Organization name

 

Employer federal ID number

 

Percent of ownership

 

Employee count

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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Subsidiary information

 

Organization name

 

Employer federal ID number

 

Percent of ownership

Employee count

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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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)

 

 

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Claim File Housing Locations

Instructions

Self-insured policy number: ______________________

• 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? _______________________________________________________

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

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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? _______________________________________________________

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

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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? _______________________________________________________

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

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Subsidiary Update Request

Instructions

Self-insured policy number: ________________________

• List all approved subsidiary entities, including address,

 

contact, phone and email information.

Company: _________________________________________

This form completed by

Name and title

Telephone number

( )

 

 

Subsidiary name: _________________________________________

 

 

Attention:_________________________________________________

 

 

Telephone number: _______________________________________

 

 

Address:__________________________________________________

The existing subsidiary has been

 

Closed

Sold

__________________________________________________________

Check if there are no changes

Email address: ____________________________________________

 

 

 

 

 

Subsidiary name: _________________________________________

 

 

Attention:_________________________________________________

 

 

Telephone number: _______________________________________

 

 

Address:__________________________________________________

The existing subsidiary has been

 

Closed

Sold

__________________________________________________________

Check if there are no changes

Email address: ____________________________________________

 

 

 

 

 

Subsidiary name: _________________________________________

 

 

Attention:_________________________________________________

 

 

Telephone number: _______________________________________

 

 

Address:__________________________________________________

The existing subsidiary has been

 

Closed

Sold

__________________________________________________________

Check if there are no changes

Email address: ____________________________________________

 

 

 

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

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Subsidiary name: _________________________________________

 

 

Attention:_________________________________________________

 

 

Telephone number: _______________________________________

 

 

Address:__________________________________________________

The existing subsidiary has been

 

Closed

Sold

__________________________________________________________

Check if there are no changes

Email address: ____________________________________________

 

 

 

 

 

Subsidiary name: _________________________________________

 

 

Attention:_________________________________________________

 

 

Telephone number: _______________________________________

 

 

Address:__________________________________________________

The existing subsidiary has been

 

Closed

Sold

__________________________________________________________

Check if there are no changes

Email address: ____________________________________________

 

 

 

 

 

Subsidiary name: _________________________________________

 

 

Attention:_________________________________________________

 

 

Telephone number: _______________________________________

 

 

Address:__________________________________________________

The existing subsidiary has been

 

Closed

Sold

__________________________________________________________

Check if there are no changes

Email address: ____________________________________________

 

 

 

 

 

Subsidiary name: _________________________________________

 

 

Attention:_________________________________________________

 

 

Telephone number: _______________________________________

 

 

Address:__________________________________________________

The existing subsidiary has been

 

Closed

Sold

__________________________________________________________

Check if there are no changes

Email address: ____________________________________________

 

 

 

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

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