OhioBWC - Basics: (Policy library) - File

UA-3 SI Policy


Policy Name:

Self-Insured Professional Employer Organization

Client Relationship Notification (UA-3SI)

Policy #:


Code/Rule Reference:

Ohio Administrative Code (OAC) 4123-17-15.1 & 4123-17-15.5 (D)(2)

Effective Date:

August 1, 2015


Self-Insured Department/Employer Services





Review Date:

August 1, 2020


         I.         Policy Purpose

This policy 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.

        II.         Applicability

The policy applies to Self-Insured Professional Employer Organizations, Client Employers and the BWC Self-Insured Department.

         III.         Definitions


A.    SI: Self-Insured.

B.    SI Employer: Self-Insuring Employer.

C.    SI-PEO: Professional Employer Organization that has been granted the privilege to self-insure for workers’ compensation purposes.

D.    Client Employer: Employer with an active State Fund policy that has been approved to participate in a PEO agreement with a SI-PEO.

E.    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.

F.     UA-3SI: Self-Insured Professional Employer Organization (SI-PEO) Client Relationship Notification.

G.    Relationship Effective Date: The lease relationship effective date recognized by BWC.


       IV.         Policy


A.    Pursuant 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.


B.    The BWC will recognize a SI-PEO lease or termination agreement with a client employer if the following criteria are met:

1.     Client employer is in an active, reinstated, or debtor in possession (DIP) policy status at the inception of the lease agreement.

2.     UA-3SI notification form is completed in its entirety, including:

a.     SI-PEO policy number and client employer policy or application number.

b.     PEO contact person and phone number;

c.     Agreement effective date;

d.     Agreement type: new, change or termination;

e.     Client employer name, address, phone, FEIN;

f.      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 (D) (2).

g.     The manual classification codes of the client employer.

h.     Signatures from a representative of the SI-PEO and client employer, title and date.

3.     A SI-PEO must submit a UA-3SI notification via email directly to the SI department at BWC Self-Insured Inquiries

C.    Upon 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.

1.     If 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 section B.

2.     If the agreement type is “All under the PEO policy”:

a.     The client employer is responsible for reporting payroll and claims under its state fund policy until BWC recognizes the agreement.

b.     The SI-PEO is responsible for reporting claims under its SI policy for a client employer until BWC recognizes the termination effective date.

3.     If the agreement type is “All under the client policy”:

a.     The client employer is responsible for reporting all payroll and claims under its state fund policy.

4.     A UA-3SI lease termination must be submitted by a PEO whenever a client employer’s state fund policy is final cancelled.

5.     A 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 number.

6.     The 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.

a.     In order for the new PEO relationship to be recognized by BWC, the existing PEO relationship must first be terminated.

b.     The current PEO is required to submit the appropriate UA3 termination notification.

7.     The SI department will notify a SI-PEO if the UA-3SI cannot be processed for any reason.

a.     The 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.

8.     On a monthly basis the SI department will identify any claims that may have been incorrectly assigned to the client employer or SI-PEO.

a.     A 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.

                                                          i.         The SI department will notify the SI-PEO in writing, to indicate the re-assignment of a claim.

                                                         ii.         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.

b.     Upon 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.

                                                          i.         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.

                                                         ii.         If reimbursement is appropriate, the SI department will credit the amount to the SI-PEO within a reasonable timeframe.


    V.         Resolution of Complaints


A.    Any 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.

Ohio Bureau of Workers’ Compensation

Attn. Self-Insured Department

30 W. Spring St., 22nd Floor

Columbus, Ohio 43215-2256

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.