The Ohio SI 7 form is an application used to renew authorization for employers to operate as self-insured entities, as mandated by Ohio law. This form requires detailed information about the employer, including corporate structure, financials, and employee counts. Ensuring that all sections are accurately completed is crucial for a successful renewal process, so don't hesitate to fill out the form by clicking the button below.
The Ohio Si 7 form plays a crucial role for employers seeking to renew their self-insured status under Ohio law. This application is essential for organizations that wish to continue operating as self-insured entities, allowing them to manage their own workers' compensation claims rather than relying on traditional insurance providers. Key components of the form include detailed company information, such as the employer's name, federal ID number, and the number of employees in Ohio. Additionally, it requests specifics about the corporate structure, including whether the entity is a corporation, partnership, or LLC. Public employers must provide additional information, such as bond ratings and compliance with SEC disclosures. The form also requires information about any subsidiaries operating under the self-insured policy, as well as the company's financial health, including gross payroll and assets. Crucially, employers must certify the accuracy of their submissions, often requiring notarization, to ensure compliance with the regulations set forth in the Ohio Revised Code. Understanding the nuances of this form can significantly impact an employer's ability to maintain self-insured status and effectively manage their workers' compensation obligations.
Application for Renewal of Authorization to Operate as a Self-insured Policy
(as outlined in Ohio Revised Code Section 4123)
Renewal date
Self-insured policy number
Instructions
•Please answer all questions. If not applicable, use symbol N/A.
•You must ile all requests for data and inancial statements, or BWC will not consider renewal of self-insurance.
Company information
Employer name (shown exactly as it is in the Articles of Incorporation)
Federal ID number
Address
Number of Ohio employees
as of application date
(including subsidiaries)
City
County
State
Nine-digit ZIP Code
Corporate contact person
Corporate phone number
Corporate FAX number
(
)
Corporate contact email
State of incorporation
Date of incorporation
Type of entity (check appropriate box)
n Corporation
n Partnership
n LLC
n Public employer*
*If you checked the public employer box, please answer the questions below:
1.
What was the self-insured applicant’s bond rating at the end of the most recent iscal year? __________________________
2.
Has the self-insured applicant complied with all SEC disclosures for the last ive years? n Yes
n No
3.
Has the self-insured applicant had any local government fund distributions withheld in the last ive years? n Yes n No
4.
Has the self-insured applicant been placed on iscal watch or emergency in the last ive years? n Yes n No
5. What were the unvoted debt capacities for the self-insured applicant for the end of the two most recent iscal years? Current year $ __________________________ Prior year $ __________________________
Are you currently administering an approved Qualiied Health Plan or Medical-Management Plan?
n QHP
n Medical-Management Plan
Ultimate USA parent information
Name of ultimate USA parent (show exactly as it is in the Articles of Incorporation)
Ultimate USA parent federal ID number
Percentage of ownership
%
Are inancials public?*
* If you answered yes to are financials public, BWC can obtain your inancials directly from your
n Yes n No
website or the SEC.
Subsidiary information
Please list subsidiary entities in Ohio, authorized by BWC to operate under this self-insured policy number. Authorized subsidiaries are listed on the Certificate of Employer's Right to Pay Compensation Directly. If an entity does not appear on your certificate, you must file an initial application for self-insurance with the self-insured department.
Organization name
Employer federal ID number
Percent of ownership
Employee count
BWC-7207 (Rev. 2/21/2013)
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SI-7
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Corporate restructuring
Please note: For BWC to properly process the referenced revisions, please provide Ohio secretary of state papers and updated organizational chart.
Has your corporate name, structure or ultimate U.S. parent changed during the past year?
If yes, please provide detailed explanation: ____________________________________________________________________________________________
Ohio administrator information
Note:This administrator must be an employee of your company. It cannot be yourTPA.
Has your Ohio administrator changed in the last 12 months? n Yes n No
Does the Ohio administrator have one or more years of experience as a workers' compensation administrator for self-insured employers in Ohio? n Yes n No
Ohio administrator's name
Ohio administrator’s fax number
( )
Ohio administrator’s email address
Authorized representative
Has the authorized representative changed in the last 12 months? n Yes n No
Representative name
Representative identiication number
Representative phone number
Email address
Excess workers' compensation insurance
Does your company carry excess workers' compensation insurance?* n Yes n No
*If you answered yes to does your company carry excess workers' compensation insurance, please submit a copy of the policies declaration page to [email protected]
Name of carrier: _____________________________________________________________________________________________________________________
Name of agent: ______________________________________________________Telephone number: (________)____________________________________
Policy number: _______________________________________________________________________________________________________________________
Current policy period: From ______________________________________ to _________________________________________________________________
Self-insured retention: ________________________________________________________________________________________________________________
Is excess insurance paying claims?*
n Yes n No *If yes, please submit claim number(s) on a separate document to [email protected]
Ohio assets and gross payroll information
Calendar and/or iscal year ending __________/__________/__________
MM DD YYYY
Ohio assets: $ ____________________________________________________
Ohio gross payroll: $ ______________________________________________
Certification
(Notary seal)
State of ______________________ County of _________________________ ss _______________________________ being duly sworn says that he/she
is the ____________________________ of ____________________________ , the employer referred to in the foregoing is true to the best of their knowledge.
Sworn to before me, this ________ day of ______________________ , 20_______ .
Notary signature
Corporate oficer signature
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Claim File Housing Locations
Self-insured policy number: ______________________
• Indicate all locations where you maintain claims records for auditing
Company: ______________________________________
purposes (including authorized reps).
This form completed by
Name and title
Telephone number
Company/authorized representative: _________________________________________________________________________
Contact name: ______________________________________________________________________________________________
Telephone number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email address: _________________________________________________________________________________________________
Date range of claims: _________________________________________________________________________________________
Approximate number of claims housed in this location? _______________________________________________________
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Subsidiary Update Request
Self-insured policy number: ________________________
• List all approved subsidiary entities, including address,
contact, phone and email information.
Company: _________________________________________
Subsidiary name: _________________________________________
Attention:_________________________________________________
Telephone number: _______________________________________
Address:__________________________________________________
The existing subsidiary has been
Closed
Sold
__________________________________________________________
Check if there are no changes
Email address: ____________________________________________
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Completing the Ohio SI 7 form is essential for renewing your self-insured policy. After filling out the form, you will need to submit it along with any required financial statements and data requests to the Bureau of Workers' Compensation (BWC) for consideration. Ensure all sections are completed accurately to avoid delays.
The Ohio Si 7 form is an application for the renewal of authorization to operate as a self-insured employer in Ohio. This form is required under the Ohio Revised Code Section 4123. It gathers essential information about the employer, including company details, financial information, and compliance with regulations. Completing this form is crucial for maintaining self-insured status and ensuring that the employer can continue to manage its workers' compensation claims independently.
Any employer in Ohio that wishes to renew their self-insured status must complete the Ohio Si 7 form. This includes corporations, partnerships, limited liability companies (LLCs), and public employers. If your company has subsidiaries operating under a self-insured policy, those details must also be included in the application. It is important that all questions are answered accurately and completely to avoid delays in processing.
The form requires a variety of information, including:
Additionally, the form asks for details about the Ohio administrator and authorized representatives, as well as information on excess workers' compensation insurance if applicable.
If you fail to submit the necessary financial statements along with your Ohio Si 7 form, the Bureau of Workers' Compensation (BWC) will not consider your renewal request. This could result in the loss of your self-insured status, which may require you to seek alternative workers' compensation coverage. It is crucial to ensure that all required documents are submitted on time to avoid any disruptions in your self-insured operations.
To ensure a smooth processing of your Ohio Si 7 application, follow these tips:
By taking these steps, you can help ensure that your application is processed without delays.
Leaving Questions Blank: Many applicants fail to answer all questions. If a question is not applicable, using "N/A" is essential. This oversight can delay processing.
Incorrect Employer Name: The employer name must match exactly as it appears in the Articles of Incorporation. Any discrepancies can lead to complications.
Missing Financial Statements: Not submitting required financial statements or data requests can result in the rejection of the renewal application.
Inaccurate Employee Count: Providing the wrong number of Ohio employees, including subsidiaries, can affect the assessment of the application.
Failure to Update Corporate Changes: If there have been any changes to the corporate name, structure, or ultimate U.S. parent, these must be disclosed. Neglecting this can raise red flags.
Not Including Subsidiary Information: All authorized subsidiaries must be listed. Failing to do so can complicate the self-insured policy.
Ignoring the Ohio Administrator Requirement: The Ohio administrator must be an employee of the company, not a third-party administrator. This requirement is often overlooked.
Missing Notary Signature: The certification section must be signed and notarized. An absent signature can invalidate the entire application.
The Ohio SI 7 form is an important document for employers seeking to renew their authorization to operate as self-insured entities. Along with this form, several other documents may be required to ensure a complete and accurate application process. Below is a list of commonly used forms and documents that accompany the Ohio SI 7 form.
Submitting these documents alongside the Ohio SI 7 form helps ensure that the application for renewal is processed efficiently. It is essential for employers to provide accurate and complete information to avoid delays in the renewal of their self-insured status.
The Ohio SI 7 form is similar to the Application for Workers' Compensation Self-Insurance in various states. This document serves as a request for companies to obtain self-insured status, allowing them to manage their own workers' compensation claims. Much like the Ohio SI 7, this application requires detailed information about the company, including financial stability and organizational structure. Both forms emphasize the importance of compliance with local regulations and necessitate the submission of supporting documentation to ensure that the applicant meets the required standards for self-insurance.
Another comparable document is the Self-Insured Employer Application in California. This application also aims to evaluate a company's eligibility to operate as a self-insured entity. Similar to the Ohio SI 7, it demands comprehensive information about the applicant's financial health and operational practices. The California application includes inquiries regarding past claims history and insurance coverage, which align with the requirements outlined in the Ohio form, ensuring that only qualified businesses can assume the responsibilities of self-insurance.
The New York Self-Insurance Application is yet another document that mirrors the Ohio SI 7. In New York, businesses seeking to self-insure must provide extensive details about their financial standing, employee count, and claims management processes. This application, like its Ohio counterpart, requires proof of compliance with regulatory standards and may necessitate additional documentation, such as financial statements and organizational charts, reinforcing the commitment to responsible self-insurance practices.
The Texas Self-Insurance Application shares similarities with the Ohio SI 7 form as well. Both documents require companies to disclose their financial information, including assets and liabilities, and to report on their claims management strategies. The Texas application also focuses on the applicant's ability to maintain adequate reserves for potential claims, paralleling the financial scrutiny present in the Ohio SI 7. This ensures that only financially stable companies are granted the privilege of self-insurance.
The Florida Self-Insured Employer Application provides another point of comparison. It requires businesses to demonstrate their financial capacity to cover workers' compensation claims independently. Like the Ohio SI 7, the Florida application includes inquiries about the company's organizational structure, employee demographics, and any past claims history. This thorough vetting process is essential for ensuring that self-insured employers can adequately manage their liabilities.
The Illinois Self-Insured Application is also akin to the Ohio SI 7 form. In Illinois, companies must present a detailed account of their financial resources and claims history to qualify for self-insurance. The application process is designed to assess the applicant's ability to handle potential claims without relying on state insurance funds, mirroring the requirements set forth in Ohio. Both forms emphasize the necessity of maintaining accurate and transparent records to foster accountability.
The Pennsylvania Self-Insurance Application reflects similar principles as the Ohio SI 7. Companies in Pennsylvania must provide extensive information about their financial stability and claims management practices. This application, much like its Ohio counterpart, requires documentation that verifies the applicant's compliance with state regulations. The focus on financial health and operational transparency is critical in both states to ensure that self-insured employers can fulfill their obligations to injured workers.
The Michigan Self-Insured Application is another document that aligns closely with the Ohio SI 7. This application demands detailed financial disclosures and an overview of the company's claims handling procedures. Both forms require businesses to demonstrate their capability to manage workers' compensation claims effectively. The emphasis on financial responsibility and compliance with state regulations is a common thread that runs through both applications.
Lastly, the Virginia Self-Insured Application mirrors the Ohio SI 7 in its approach to assessing a company's eligibility for self-insurance. Virginia's application requires businesses to provide financial statements, employee counts, and other relevant information to evaluate their capacity to self-insure. Like the Ohio SI 7, the Virginia application stresses the importance of maintaining adequate resources to cover potential claims, ensuring that only qualified entities can assume the risks associated with self-insurance.
When filling out the Ohio SI 7 form, attention to detail is crucial. Here are five essential dos and don'ts to ensure a smooth application process.
Understanding the Ohio Si 7 form can be crucial for employers looking to operate as self-insured entities. However, there are several misconceptions that often arise. Here are seven common misunderstandings about the Ohio Si 7 form, along with clarifications:
This form is primarily used for the renewal of existing self-insured policies, not just for new applications. Employers must file it to maintain their self-insured status.
If a question is not applicable, employers can simply mark it as N/A. It’s important to provide accurate information, but detailed explanations are not always necessary.
Employers must also submit financial statements and other requested data. Without these, the renewal may not be considered by the Bureau of Workers' Compensation (BWC).
The Ohio administrator must be an employee of the company. Using a TPA for this role is not allowed, ensuring that the employer has direct oversight.
Submitting the form late can lead to complications in the renewal process. It’s advisable to adhere to deadlines to avoid any disruptions in self-insured coverage.
Even if there are no subsidiaries, employers must still provide their financial information as part of the renewal process. This helps the BWC assess the overall financial health of the self-insured entity.
This form must be submitted regularly, typically annually, to ensure that the self-insured status remains active. Employers should stay updated on renewal dates and requirements.
Complete all sections of the Ohio SI 7 form accurately. If a question does not apply, indicate with "N/A."
Provide the correct corporate information, including the employer name as it appears in the Articles of Incorporation and the federal ID number.
Include financial statements and data requests, as these are necessary for the renewal of self-insurance.
Ensure that the Ohio administrator listed has relevant experience and is an employee of the company, not a third-party administrator.
Submit any required documentation, such as excess workers' compensation insurance declarations, to the appropriate email address.