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OhioBWC - Employer:  (Instructions for the completion of the Handicap Reimbursment Election (SI-41))

Instructions for the completion of the Handicap Reimbursment Election

If the employer elects not to participate in the handicap reimbursement program in which BWC offers employers incentives to hire handicapped persons, then complete the following form and include with the remainder of the packet of requested information. This election is irrevocable, once it is made.

  1. Risk No.: Enter your risk number.
  2. Certification Line: Enter the name of the company as it appears in the articles of incorporation.
  3. Signature: A person authorized to sign for your company should sign the form.
  4. Title: Enter the title of the person signing the form.
  5. Date: Enter the date that the form was signed.
Print Handicap Reimbursement Election Form (SI-41)