The Ohio UA-3 form is a critical document used to inform the Bureau of Workers' Compensation (BWC) about changes in the client relationship of a Professional Employer Organization (PEO). This form is essential for notifying BWC of new clients, changes to existing client relationships, or the termination of a client. Timely submission is key, as the BWC requires notifications to be received within specific time frames to ensure compliance.
The Ohio UA-3 form plays a crucial role in the relationship between Professional Employer Organizations (PEOs) and their clients. This form is essential for notifying the Bureau of Workers' Compensation (BWC) about various changes in client relationships, including new contracts, modifications, or terminations. Timeliness is key; the BWC requires that notifications regarding new contracts be submitted within 30 days of their effective date, while terminations must be reported within 14 days. If these deadlines are not met, the BWC will recognize the date the UA-3 is received as the effective date, which could lead to complications. The form captures important details, such as the names and policy numbers of both the PEO and the client, as well as the specifics of the lease arrangement. It also includes sections for reporting employee classifications and payroll information, ensuring that both parties are aligned on their responsibilities. Signatures from both the client and the PEO are mandatory, affirming that all information provided is accurate and complete. Any omissions or misrepresentations could result in serious consequences, including the potential revocation of registration. Understanding the importance of the Ohio UA-3 form is vital for maintaining compliance and fostering a smooth working relationship between PEOs and their clients.
Professional Employer Organization
Client Relationship Notification
Instructions
Use this form to notify BWC of a new client, change of relationship with a current client or termination of a client.
Mail this form to BWC, PEO Unit, 22nd Floor, 30 W. Spring St., Columbus, OH 43215-2256, or send a fax to 614-719-5925.
BWC must receive new contract notification within 30 days of the effective date of the contract. BWC must receive contract termination notifications within 14 days of the effective date of the termination.
Notice: Pursuant to Ohio Administrative Code 4123-17-15.1(B), if BWC is not notified within the required time frame, BWC will recognize the date the UA-3 is received as the effective date.
Professional employer organization (PEO) information
Company name
Policy number
Contact person name
Telephone number
PEO lease information
Check only one
Change existing policy number reporting client
Effective date of lease, termination or change in
New lease
payroll/claims
Ohio
Lease termination
Change to portion of client’s employees assumed by PEO
(No splitting of employees within a manual classification)
Client company information
Client company name
Client policy number
DBA
Federal ID number
Mailing address (P.O. Box if applicable)
Client phone number
City
State
Nine-digit ZIP code
Employee reporting (payroll and claims)
List class codes reportable by PEO
List class codes reportable by client
All under the PEO policy
PEO
Client
All under the client policy
A portion under the PEO policy
(Partial wages reported to BWC under the
client policy must be reported under the
FEIN of the client employer)
Signatures are required by both parties
Title
Date
Print client signatory
Client signature
Print PEO signatory
PEO signature
Note: Signing this form is an acknowledgement that all the information listed on this form is complete and true to the best of your knowledge. Omission of any of the items required or intentional misrepresentation of any of the above information on this form may lead to registration revocation as outlined in Ohio Revised Code Section 4125.
BWC-8003 (May 15, 2014)
UA-3
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