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OhioBWC - Employer:  (Instructions for the completion of the Agreement Between Employer and the Ohio Bureau of Workers Compensation Regarding Amount of Self-Insured Buyout (SI-16))

Instructions for the completion of the Agreement Between Employer and the Ohio Bureau of Workers' Compensation Regarding Amount of Self-Insured Buyout
(SI-16)

  • Employers name: Enter the employers name as it appears in the articles of incorporation on the first blank line of the form.
  • Location: Enter the city in Ohio where the employer’s principal location is located in the second blank line.
  • Buy-out amount: In the blank line in number 2 on the form, enter the amount of the buy-out that has been provided by BWC.
  • Large blank area after number 4(A): Enter the information as described in the text.
  • Next large blank area after number 4(A): BWC will enter this information.
  • Blank lines at bottom of form: Enter the date signed, the month signed and year, city/state, signature of someone authorized to sign for the employer and the name of the employer as it appears in the articles of incorporation on each successive line at the bottom of the form.
Print Self-Insured Buyout Form (SI-16)


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