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
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: $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 individual-retrospective rating.
Estimated policy year payroll - Provide estimated payroll you will report during the
policy year for each manual classification assigned to your policy number. The public
taxing district policy year is Jan. 1 to Dec. 31.
Use National Council on Compensation Insurance (NCCI) manual
classification numbers or BWC 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. BWC 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