You must include both your federal identification and policy numbers
on this form.
Enter your company name and telephone number. Also, enter city, state
and nine-digit ZIP code.
You must select one of the following individual-retrospective rating
plan parameters. Your selection will determine the minimum and maximum
level, as well as the exposure to claims losses. Choose one claim
limit and one maximum premium limit from the following Tier I parameters:
Tier I parameters
- Claim limit: $100,000, $200,000, $300,000, $400,000,
no claim limit;
- Maximum premium: 150 percent or 200 percent.
Tier II parameters
If you do not meet the requirements for Tier I do you want to be
considered for Tier II?
If so, choose one of the following claim limits: $100,000 or
$125,000. Tier II offers a maximum premium of 150 percent.
Tier II eligibility requirements are the same as Tier I except
if you have entered into any partial payment arrangements
with BWC, this will not preclude you from being considered for
Estimated policy year payroll - Provide estimated payroll you will report
during the policy year for each manual classification assigned to your
policy number. The private employer policy year is July 1 to June 30.
Use National Council on Compensation Insurance (NCCI) manual
classification numbers, or we will reject your application.
Payroll rounded to the nearest thousand dollars
(List all NCCI manual classifications below.)
Owner partner officer
*You can access additional pages if necessary for
Statement of agreement: I have read the individual-retrospective
rating rules in their entirety. I understand the rules and agree
with the terms of the individual-retrospective rating plan.
Note: BWC must review and approve the application before
it becomes effective. We will notify you in writing when the
application is approved and the applicable minimum premium
* If you are applying for the first time, you must submit
five years of audited financial information.
If you are reapplying, you only need to submit the previous
year’s audited financial statement. Mail this information
within five calendar days to:
30 W. Spring St., 22nd floor
Columbus, OH 43215-2256