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
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.