The Ohio Si 7 form serves as the Application for Renewal of Authorization to Operate as a Self-insured Policy, as specified in the Ohio Revised Code Section 4123. This essential document ensures that employers maintain their self-insured status by providing necessary company information and financial data. Completing the form accurately is crucial for a smooth renewal process and compliance with state regulations.
The Ohio SI 7 form serves as a crucial application for employers seeking to renew their authorization to operate as self-insured entities. This form is guided by the Ohio Revised Code Section 4123, and it requires detailed information about the employer, including their corporate structure, financial stability, and employee count. When completing the SI 7, employers must provide their federal ID number, the number of Ohio employees, and various details regarding their corporate structure, such as whether they are a corporation, partnership, or public employer. Additionally, the form asks for information on any subsidiaries operating under the self-insured policy, as well as specifics about the company's financial health, including bond ratings and compliance with SEC disclosures. Employers are also required to disclose their excess workers' compensation insurance status, if applicable. Notably, the form emphasizes the importance of accuracy and completeness, urging applicants to use "N/A" for questions that do not apply to them. As part of the renewal process, the Bureau of Workers' Compensation (BWC) expects all necessary financial statements to be submitted; otherwise, the renewal may not be considered. Understanding the requirements and implications of the Ohio SI 7 form is essential for employers aiming to maintain their self-insured status and ensure compliance with state regulations.
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 SIINQ@bwc.state.oh.us
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 siinq@bwc.state.oh.us
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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