OhioBWC - Employer:  (Instructions for the completion of the Election to Withdraw from Claims Reimbursement Fund (SI-44))
Instructions for the completion of the Election to Withdraw from Claims Reimbursement Fund
(SI-44)
If the employer elects not to participate in the claims reimbursement program that reimburses self-insuring employers for overturned claims, then complete the following form and include with the remainder of the packet of requested information. This election is irrevocable.

  1. Employer: Enter the name of the company as it appears in the articles of incorporation.
  2. Signature: A person authorized to sign for your company should sign the form.
  3. Title: Enter the title of the person signing the form.
  4. Date: Enter the date that the form was signed.
Print Election to Withdraw from Claims Reimbursement Fund Form (SI-44)