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Instructions for the completion of the
Information Update Request (SI-6 PG. 2)
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Requests information regarding the organization’s structure, payroll and claims management locations.
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Self-Insured Risk No.: Enter this number if it
has been assigned by BWC. If not, leave it blank.
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Company: Enter company name as it appears in the
articles of incorporation.
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Name and Title: Enter the name and title of the
person filling out the form.
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Area Code and Telephone Number: Enter the phone
number of the person filling out the form.
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In each of the subsections list the
information that applies to each payroll center. A payroll center is a
location that collects payroll information to be reported by the location
listed in number 1 on the form. In the first subsection, list the information
for the location that will complete the SI-40 Report of Paid Compensation.
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Hourly Employees: Enter the number of hourly
employees at each location listed.
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Salaried Employees: Enter the number of salaried
employees at each location listed.
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1. Company: Enter the name of the location that
will be complete the DP-21 Payroll Report. This should be the same for all
locations listed on the form.
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DBA/Division: Enter this information for the
location and subsection of the form for which information is being listed.
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Attention: Enter the contact person’s name for
that location.
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Telephone #: Enter the contact person’s
telephone number for that location.
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Address: Enter the street, city, state, and 9
digit zip code for the located being listed.
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2. Payroll Center: Check yes or no in the
appropriate box. The first location lised will be “yes”, the others will be
“No”.
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3. Claim Files Maintained: Check yes or no
depending on if claim files are maintained by the location for which
information is being entered.
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Use additional sheets as necessary for additional
locations. Please note that this is two sided form.
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- Agreement Between Employer and
the Ohio Bureau of Workers’ Compensation Regarding Amount of Self-Insured
Buyout (SI-16).
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When an employer becomes self-insured, it is liable for its proportionate share
of any deficit in the state insurance fund as determined by BWC’s actuarial unit.
Because BWC ended fiscal year 1999 with no deficit, employers that file an
appropriate application from July 1, 2000 through June 30, 2001 will incur no
liability nor will they receive any refund of prior premiums paid. BWC re-evaluates
the need for a buyout on an annual basis. The employer will pay the determined amount
within 30 days of the granting of self-insurance.
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Note: There is currently no buyout amount, however the form is still required.
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