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OhioBWC - Employer:  (Instructions for the completion of the Initial Application by Employers for Authority to Pay Compensation Etc. Directly (SI-6))

Instructions for the completion of the Initial Application by Employers for Authority to Pay Compensation Etc.Directly (SI-6)
Company Information:
  1. Name of applicant - Enter the name of the employer shown exactly as it is in the Articles of Incorporation.
  2. Present State Fund Risk No. – Enter the employer’s current policy number
  3. Federal I. D. Number – Enter the employer’s Federal Employer Identification Number
  4. Address: Enter the employer’s street address and P. O. Box , if applicable
  5. City: Enter the State
  6. County: Enter the County
  7. Zip Code: Enter the 9 digit Zip Code
  8. Type of Entity: (Check the appropriate box.) Check the appropriate box.
  9. State of Incorporation: Enter the appropriate state.
  10. List of partners if a partnership: List Name, home address and appropriate designation for each partner. Use additional sheets if necessary.
Subsidiary Section: Complete only if a subsidiary of another entity
  1. Name of ultimate USA parent: Enter as it appears in the articles of incorporation
  2. Ultimate USA parent Federal I.D. Number: Enter that entity’s Federal Employer Identification number
  3. State of Incorporation: Enter the appropriate state
  4. Date of Incorporation: Enter the appropriate date.
  5. Percentage of Ownership: Enter the percentage of ownership of the subsidiary
  6. Attach a detailed organizational chart.
Additional Application Information (Page 2 of Application)
  1. Enter the number of years and months that you have been operating in Ohio under the state fund policy number indicated on the front of the form.
  2. Check yes or no in the boxes depending on whether or not you ever carried Ohio Workers’ Compensation under any other name or risk number
If yes, enter the following information:
  1. Company name: Enter the name of that company.
  2. Risk Number: Enter the risk number of that company
  3. Check the appropriate box as to whether you purchased all or part of the business.
  4. Check the appropriate box as to whether the other business was operating or inactive at the time of purchase.
  5. What is the nature of the business of the applicant employer within the state of Ohio: Enter as much information to adequately describe the business operations.
  6. What was the date of commencement, or is the date of commencing business within the state of Ohio: Enter the appropriate date.
  7. Enter manual number(s), manual description(s), and number of employees in each manual as instructed. Use additional sheets if necessary.
Financial Information
  1. Total Ohio assets at end of last fiscal or calendar year: Enter the amount.
  2. Total Ohio gross payroll for last calendar year or fiscal year: Enter the amount.
Certification
The form must be notarized per normal notary procedures.

Instructions for the completion of the Information Update Request (SI-6 PG. 2)


Requests information regarding the organization’s structure, payroll and claims management locations.
  • Self-Insured Risk No.: Enter this number if it has been assigned by BWC. If not, leave it blank.
  • Company: Enter company name as it appears in the articles of incorporation.
  • Name and Title: Enter the name and title of the person filling out the form.
  • Area Code and Telephone Number: Enter the phone number of the person filling out the form.
In each of the subsections list the information that applies to each payroll center. A payroll center is a location that collects payroll information to be reported by the location listed in number 1 on the form. In the first subsection, list the information for the location that will complete the SI-40 Report of Paid Compensation.
  1. Hourly Employees: Enter the number of hourly employees at each location listed.
  2. Salaried Employees: Enter the number of salaried employees at each location listed.
  3. 1. Company: Enter the name of the location that will be complete the DP-21 Payroll Report. This should be the same for all locations listed on the form.
  4. DBA/Division: Enter this information for the location and subsection of the form for which information is being listed.
  5. Attention: Enter the contact person’s name for that location.
  6. Telephone #: Enter the contact person’s telephone number for that location.
  7. Address: Enter the street, city, state, and 9 digit zip code for the located being listed.
  8. 2. Payroll Center: Check yes or no in the appropriate box. The first location listed will be “yes”, the others will be “No”.
  9. 3. Claim Files Maintained: Check yes or no depending on if claim files are maintained by the location for which information is being entered.

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