Instructions for the completion of the Initial Application by Employers for
Authority to Pay Compensation Etc.Directly (SI-6)
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Company Information:
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Name of applicant - Enter the name of the
employer shown exactly as it is in the Articles of Incorporation.
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Present State Fund Risk No. – Enter the
employer’s current policy number
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Federal I. D. Number – Enter the employer’s
Federal Employer Identification Number
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Address: Enter the employer’s street address
and P. O. Box , if applicable
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City: Enter the State
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County: Enter the County
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Zip Code: Enter the 9 digit Zip Code
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Type of Entity: (Check the appropriate box.) Check the appropriate box.
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State of Incorporation: Enter the appropriate state.
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List of partners if a partnership: List Name,
home address and appropriate designation for each partner. Use additional sheets
if necessary.
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Subsidiary Section: Complete only if a
subsidiary of another entity
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Name of ultimate USA parent: Enter as it
appears in the articles of incorporation
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Ultimate USA parent Federal I.D. Number: Enter
that entity’s Federal Employer Identification number
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State of Incorporation: Enter the appropriate state
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Date of Incorporation: Enter the appropriate date.
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Percentage of Ownership: Enter the percentage of ownership of the subsidiary
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Attach a detailed organizational chart.
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Additional Application Information (Page 2 of Application)
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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.
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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
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If yes, enter the following information:
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Company name: Enter the name of that company.
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Risk Number: Enter the risk number of that company
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Check the appropriate box as to whether you purchased all or part of the business.
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Check the appropriate box as to whether the other business was operating or inactive at the time of purchase.
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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.
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What was the date of commencement, or is the date of commencing business within the state of Ohio: Enter the appropriate date.
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Enter manual number(s), manual description(s), and number of employees in each manual as instructed. Use additional sheets if necessary.
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Financial Information
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Total Ohio assets at end of last fiscal or calendar year: Enter the amount.
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Total Ohio gross payroll for last calendar year or fiscal year: Enter the amount.
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Certification
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The form must be notarized per normal notary procedures.
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Instructions for the completion of the Information Update Request (SI-6 PG. 2)
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Requests information regarding the organization’s structure, payroll and claims management locations.
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Self-Insured Risk No.: Enter this number if it
has been assigned by BWC. If not, leave it blank.
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Company: Enter company name as it appears in the
articles of incorporation.
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Name and Title: Enter the name and title of the
person filling out the form.
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Area Code and Telephone Number: Enter the phone
number of the person filling out the form.
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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.
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Hourly Employees: Enter the number of hourly
employees at each location listed.
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Salaried Employees: Enter the number of salaried
employees at each location listed.
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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.
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DBA/Division: Enter this information for the
location and subsection of the form for which information is being listed.
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Attention: Enter the contact person’s name for
that location.
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Telephone #: Enter the contact person’s
telephone number for that location.
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Address: Enter the street, city, state, and 9
digit zip code for the located being listed.
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2. Payroll Center: Check yes or no in the
appropriate box. The first location listed will be “yes”, the others will be
“No”.
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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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