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OhioBWC - Employer - Form: (Wellness Grant Application) - Introduction

Application for Workplace Wellness Grant Program (SH-27)

Introduction
Employers wanting to improve the health and wellness of their workers can benefit this program which provides funding to assist employers in establishing training and programs to reduce health risk factors specific to their employees. To learn more about eligibility and program requirements, go to the Program overview page.



Additional information
As a grant recipient the state considers you a state vendor. This means you must complete the following three forms and send them to Ohio Shared Services.

  • Vendor Information Form (OBM-5657) - Verify all fields are complete and the form is signed. We do not accept electronic signatures. Also, verify information contained on the W-9 matches that provided on this form, specifically, legal business name, taxpayer ID # (TIN), and business type/business entity.
  • Request for Taxpayer Identification Number & Certification (W-9) - Complete all applicable sections of the document, including taxpayer type, a valid tax identification number and responsible party's signature. We do not accept electronic signatures. The information you provide must match how you're registered with the Internal Revenue Service (IRS). You can find instructions for completing the form on the IRS website. Should you require additional assistance, contact the IRS at 1-800-829-1040.
  • Authorization Agreement for Direct Deposit of EFT Payments (OBM-4310) - The preferred method of payment for the State of Ohio is electronic funds transfer (EFT); complete this form and include a current voided check or bank letter. The agreement contains instructions
Send the completed forms to:
Vendor Maintenance
Ohio Shared Services
Email: vendor@ohio.gov
Fax: 614-485-1052
Mail: P.O. Box 182880
Columbus, Ohio 43218-2880

If you have questions, contact Ohio Shared Services at 1-877-OHIOSS1 (1-877-644-6771) or 614-338-4781.

Contract agreement
We will not approve your application without the submission of the signed legal agreement. Download the agreement, sign, and mail the document to the following address:
Workplace Wellness Grant Program
13430 Yarmouth Drive
Pickerington, OH 43147-8310

All signatures must be original.



Required information
  • Policy number, federal tax ID or Social Security number
  • Whether you currently have a wellness program with a health-risk appraisal and biometric assessment
  • Whether you have a wellness program with healthy promotion and activities designed to address heath risk factors
  • Program contact name, phone number, email address and title
  • Budget- Type of service(s) and Estimated cost(s)
  • Narrative - Current wellness situation
  • Proposed program - Number of employees interested, wellness culture, timeline for implementation

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