Self-Insured Professional Employer Organization
Client Relationship Notification (UA-3SI)
Administrative Code (OAC) 4123-17-15.1
August 1, 2015
Self-Insured Department/Employer Services
August 1, 2020
defines the responsibilities of a Self Insured Professional Employer
Organization (SI-PEO) to notify the BWC Self Insured Department of a PEO
agreement with a client employer.
The policy applies to Self-Insured Professional Employer Organizations,
Client Employers and the BWC Self-Insured Department.
A. SI: Self-Insured.
B. SI Employer: Self-Insuring
SI-PEO: Professional Employer Organization that has been granted the
privilege to self-insure for workers’ compensation purposes.
Client Employer: Employer with an active State Fund policy that
has been approved to participate in a PEO agreement with a SI-PEO.
PEO Lease Agreement: Written contract between a professional
employer organization (SI-PEO) and a client employer for a duration of not less
than twelve (12) months.
UA-3SI: Self-Insured Professional Employer Organization (SI-PEO)
Client Relationship Notification.
Effective Date: The lease relationship effective date recognized by BWC.
to OAC 4123-17-15.1, a SI-PEO
must notify the BWC SI department within thirty (30) days of entering into or
changing a lease agreement with a client employer, and fourteen (14) days of
terminating a lease agreement with a client employer, using the UA-3SI.
BWC will recognize a SI-PEO lease or termination agreement with a client employer
if the following criteria are met:
employer is in an active, reinstated, or debtor in possession (DIP) policy
status at the inception of the lease agreement.
notification form is completed in its entirety, including:
policy number and client employer policy or application number.
contact person and phone number;
type: new, change or termination;
employer name, address, phone, FEIN;
Reporting type: “All under PEO Policy” or “All under Client Policy”. Partial
reporting agreements are not permitted for a SI-PEO pursuant to OAC 4123-17-15.5
manual classification codes of the client employer.
from a representative of the SI-PEO and client employer, title and date.
SI-PEO must submit a UA-3SI notification via email directly to the SI department
at BWC Self-Insured Inquiries.
receipt of a UA-3SI notification, the SI department will send a written notice
to the SI-PEO and client employer confirming the PEO agreement and indicating
the effective date recognized by BWC.
the UA-3SI agreement is not received within the required timeframes, thirty (30)
days of a new lease effective date, or fourteen (14) days of a terminated lease
effective date, BWC will recognize the agreement on the date the SI department
receives the UA-3SI, provided the agreement meets the criteria outlined in
the agreement type is “All under the PEO policy”:
client employer is responsible for reporting payroll and claims under its state
fund policy until BWC recognizes the agreement.
SI-PEO is responsible for reporting claims under its SI policy for a client
employer until BWC recognizes the termination effective date.
the agreement type is “All under the client policy”:
client employer is responsible for reporting all payroll and claims under its
state fund policy.
UA-3SI lease termination must be submitted by a PEO whenever a client
employer’s state fund policy is final cancelled.
UA-3SI lease change notification must be submitted when there is a change in
the reporting type, client employer business name or client employer policy
BWC will not recognize a new PEO/Client Relationship agreement when a client employer
is in an active PEO relationship with another State Fund or SI-PEO.
In order for the new PEO relationship to be recognized by BWC, the
existing PEO relationship must first be terminated.
The current PEO is required to submit the appropriate UA3 termination
SI department will notify a SI-PEO if the UA-3SI cannot be processed for any
PEO will be given five (5) business days to resolve the issue, and if the issue
is not resolved within the timeframe the PEO will be required to submit a UA-3SI.
a monthly basis the SI department will identify any claims that may have been
incorrectly assigned to the client employer or SI-PEO.
claim assigned to the client employer with a date of injury on or after the recognized
PEO agreement effective date will be re-assigned to the SI-PEO policy, and the
SI-PEO policy will be recognized as the employer of record.
The SI department will notify the SI-PEO in writing, to indicate the
re-assignment of a claim.
All costs paid by the state insurance fund prior to the re-assignment of
a claim will be billed dollar-for-dollar to the SI-PEO.
a determination by the SI department that a claim was incorrectly assigned to
the SI-PEO, the claim will be re-assigned to the client employer.
The SI-PEO may submit a written request to the SI department for
reimbursement of any costs paid in the claim, along with proof of payment.
If reimbursement is appropriate, the SI department will credit the
amount to the SI-PEO within a reasonable timeframe.
Resolution of Complaints
complaints or disputes related to this policy must be submitted in writing to
the SI department via mail or email as detailed in the Self-Insured
Resolution of Complaints Policy.
of Workers’ Compensation
Spring St., 22nd Floor
Email: BWC Self-Insured Inquiries.
B. The SI
department will issue a formal written response to any complaint. If the
complaint is not resolved as a result of the formal response issued by the SI
department, a written request that the issue be referred to the Self-Insured
Review Panel (SIRP) may be submitted by the SI employer or SI-PEO.