U118 Form – Fill Out and Use This PDF

Notification of Business

Acquisition/Merger or Purchase/Sale

Have questions? Need assistance? BWC is here to help!

Call 1-800-OHIOBWC, 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 ohiobwc.com

Use this form to notify BWC when succeeding, in whole or in part, another in the operation of a business.

If you are the successor/new employer and do not have Ohio workers’ compensation coverage, you must complete an Application for Ohio Workers’ Compensation Coverage (U-3). If you have Ohio workers’ compensation coverage, you only need to submit the U-118.

Ohio workers’ compensation rule (Rule 4123-17-02 Basic or manual rate) requires an employer that succeeds another employer in the operation of a business, in whole or in part, to notify BWC of the succession. Additionally, the succeeding employer must preserve the former employer’s payroll records for the ive years preceding the date of succession.

Whenever one employer succeeds another employer in the operation of a business, in whole or in part, BWC requires information on the succession to calculate the experience rating of the succeeding employer. Additionally for successions taking place on or after Sept. 1, 2006, where one employer wholly succeeds in the operation of a business, BWC shall transfer to the successor any and all existing and future liabilities or credits of the former employer in addition to the experience transfer.

If an employer purchases or acquires only a portion of the business, BWC transfers only that portion of the former employer’s experience to the succeeding employer. BWC will inspect the former employer’s payroll and claims records to determine what should transfer to the successor for rate calculation purposes.

Notify BWC by following these steps:

1Complete all sections of this form and provide as many details as possible to avoid unnecessary requests for additional information;

2 Sign and date the form;

3Mail the completed form to: Ohio Bureau of Workers’ Compensation Policy Processing, 22nd floor

	OR	30 W. Spring St.
		Columbus, Ohio 43215-2256

4 Fax completed form to: Policy processing 614-719-5313.

Section A - General information

Provide general information for the succeeding new employer and former employer. If you are the successor/new employer and do not have Ohio workers’ compensation coverage, you must complete the U-3 application. You can obtain the U-3 application by visiting BWC’s Web site at ohiobwc.com or by calling 1-800-OHIOBWC. You can submit the U-3 application online at ohiobwc.com.

Section B - Transaction detail to be completed by the former employer

BWC uses the information provided in this section to determine if a succession has occurred. BWC evaluates criteria, including but not limited to, criteria listed below to make this determination.

•Business ownership

•Continuity of business operations

•Real estate, plant and equipment, material inventories and other real property

•Customer proiles

•Industrial pursuit

•Employee roster

Section C - Transaction detail to be completed by the new/successor employer

BWC uses the information provided in this section to determine if a succession has occurred. BWC evaluates criteria, including but not limited to, criteria listed below to make this determination.

•Business ownership

•Continuity of business operations

•Real estate, plant and equipment, material inventories and other real property

•Customer proiles

•Industrial pursuit

•Employee roster

Section D - Certiication

This section is where the parties associated with the transaction read the certiication statement and provide their signatures. BWC has the authority to proceed with processing the transaction without the signature or agreement of one or both of the parties.

BWC-7624 Rev. 10/28/2010

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U-118

SECTION A - General information

If you do not have Ohio workers’ compensation coverage, you must complete and submit the U-3 application. You can obtain the U-3 application at ohiobwc.com or by calling 1-800-OHIOBWC.

Succeeding employer - complete section A, C and D only

Former employer - complete section A, B and D only

Legal business name	Ohio workers compensation policy number
Trade name or doing business as name (DBA)	Telephone number

SECTION B - Transaction detail to be completed by the former employer

1.On what date did you sell the business?

2.If you are no longer operating in Ohio, what was the date you last employed Ohio employees?

3.Did you sell n all or n part of your business? If this is a partial acquisition or sale, of an existing business, explain what portion or location of the entire operation was sold.

4.Is there a purchase/sale agreement associated with this transaction? n Yes n No (BWC may request a copy of the purchase/ sale agreement.)

5.Do you continue to operate any additional Ohio locations under this policy? n Yes n No Explain:

6.Provide the names of all partners, corporate oficers or individuals that have ownership interest for the former and succeeding employer.

	Ownership interests for former employer				Ownership interests for succeeding employer
7.	Has the business been in continuous operation? n Yes n No
	Explain:
8.	Is the succeeding employer continuing to operate in the same location? n Yes n No
	Explain:
9.	How many employees did you have prior to the sale? ________________________

U-118 2 of 4

Policy number

SECTION B - Transaction detail to be completed by the former employer (continued)

12. Provide any additional information you believe pertinent to this transaction. (Attach additional information as needed)

SECTION C - Transaction detail to be completed by the new/successor employer

4.Provide the names of all partners, corporate oficers or individuals that have an ownership interest for the New/Successor and former employer.

5.Did you acquire n all or n part of an existing business? Please explain what was acquired or purchased.

U-118 3 of 4

Policy number

SECTION C - Transaction detail to be completed by the new/successor employer (continued)

SECTION D - Certification

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

Furthermore, I am aware that pursuant to BWC Rule 4123-17-02 Basic or manual rate BWC shall transfer the former employer’s rights and obligations under the workers’ compensation law to the successor employer in addition to any credits of the former employer when one employer wholly succeeds in the operation of the business. Where one employer wholly or partially succeeds in the operation of the business, the experience of the former employer will be transferred to establish the rate of the succeeding employer.

Succeeding employer

Signature of owner, partner, member or executive oficer	Title
Print name of above signature	Date
Telephone number	E-mail

Former employer

Signature of owner, partner, member or executive oficer	Title
Print name of above signature	Date
Telephone number	E-mail

BWC has the right to proceed with processing a transaction to transfer the former employers experience and the liabilities or credits when the successor wholly succeeds another employer in the operation of a business without one or both of the parties’ signature or approval.

U-118 4 of 4