EMPLOYER DISCLOSURE FORM

This Employer Disclosure and the Temporary Authorization forms must be completed, signed and returned to the ACTUARIAL SECTION below. DO NOT SEND THESE DIRECTLY TO THE OHIO BWC.

FROM:

BWC POLICY _______________________________________

COMPANY NAME ____________________________________

DOING BUSINESS AS _________________________________

GROUP RATING CONTACT_____________________________

ADDRESS __________________________________________

___________________________________________________

TELEPHONE NO (____)__________________________________

FAX NO (____)________________________________

E-MAIL ADDRESS___________________________________

If you would prefer for information regarding Group Rating to be sent to a location other than that in the box to the left, please complete the following information:

NAME ____________________________________

ADDRESS _________________________________

__________________________________________

TELEPHONE NO (____)___________________

FAX NO (____)_________________________

E-MAIL ADDRESS

__________________________________________

GROUP RATING DISCLOSURE STATEMENT

I. REPORT OF MAJOR INJURIES

Please check if your business has had any of the following types in injuries within the last two (2) calendar years: NO CLAIMS

Amputation Loss of eyesight    Spinal cord trauma     Any injury resulting in the payment of more

than four (4) weeks of compensation

Hospitalization for burn treatment   Back surgery   Death

If any of the above are checked, please list claims(s) below and use additional pages if necessary:

Claim No.          Employee Name                       Nature of Injury                                                  Return to work (date)

 

 

II. PLEASE ANSWER EACH OF THE FOLLOWING

Is your company a Professional Employer Organization (PEO)? YES NO

If yes, please attach list of clients for whom you are the employer of record, who have contracted with your organization since July 1, 1997.

Has your company been a client of a professional employer organization (PEO) after July 1, 1997? YES NO

If yes, please list the PEO your employees were covered by and attach a list of any injuries that occurred during that time_______________________________

Has your company acquired or merged with the another company(s) during the last five (5) years? YES NO

If yes, please note their name(s)___________________________________________________and BWC policy number(s) ____________________________

Has your company or owners of your company operated under a different policy number within the last five (5) years? YES NO

If yes, please note their name(s)___________________________________________________and BWC policy number(s) ____________________________

III. CERTIFICATION BY CORPORATE OFFICER/OWNER/PARTNER

I certify that the disclosure information is true to the best of my knowledge.

 

_________________________________________________               _________________________________________________ 

Signature                                                                                                  Title

_________________________________________________               _________________________________________________ 

Print Name                                                                                                Date

Association: Ohio Automobile Dealers Association