The Ohio Si 7 form serves as an Application for Renewal of Authorization to Operate as a Self-insured Policy, in alignment with the Ohio Revised Code Section 4123. This crucial document outlines the renewal process for companies operating under self-insured policies, delineating specific requirements including company information, financial statements, and compliance with regulatory standards. Through answering all mandated questions and providing essential data, companies maintain their self-insured status, securing their ability to manage workers' compensation claims independently.
In Ohio, businesses aiming to manage their workers' compensation insurance directly must navigate the intricate process outlined in the Ohio Si 7 form, officially known as the Application for Renewal of Authorization to Operate as a Self-insured Policy. This critical document, mandated by Ohio Revised Code Section 4123, requires detailed information on a company's operations, including corporate structure, subsidiary details, and financial health. Employers must disclose their number of employees, corporate contacts, and the status of any qualified health plans or medical management plans they administer. Additionally, the form inquiries about changes in corporate name or structure, the existence of excess workers' compensation insurance, and specifics about Ohio assets and payroll. For public employers, it also probes compliance with SEC disclosures and fiscal health indicators, such as bond ratings and government fund distributions. Notably, the form stipulates the necessity of housing locations for claim files, underscoring the importance of orderly record-keeping for audit purposes. This comprehensive form not only serves as a renewal application but also provides the Bureau of Workers' Compensation (BWC) with essential data to assess a company's eligibility and capability to self-insure, emphasizing the need for accuracy and completeness in its submission.
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)
1 | Page
SI-7
2 | Page
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
3 | Page
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? _______________________________________________________
4 | Page
5 | Page
6 | Page
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: ____________________________________________
7 | Page
8 | Page
The Ohio SI-7 form is essential for entities seeking renewal of authorization to operate as self-insured businesses under Ohio's workers' compensation laws. Proper completion of this form ensures seamless continuation of self-insurance privileges, avoiding potential lapses in coverage. The process involves providing detailed organizational, financial, and policy information to the Ohio Bureau of Workers' Compensation (BWC). The goal is to demonstrate the ongoing capability to self-insure, including the strength of financial resources and compliance with regulatory requirements. Below are detailed instructions that will aid in the accurate completion of the SI-7 form.
This comprehensive completion of the SI-7 form is your step towards maintaining the authorization to self-insure in Ohio, ensuring that your company continues to meet all requisite legal and financial standards.
What is the Ohio Si 7 form?
The Ohio Si 7 form, officially known as the Application for Renewal of Authorization to Operate as a Self-insured Policy, is necessary for employers in Ohio seeking to renew their status as a self-insured entity, as mandated by the Ohio Revised Code Section 4123. This status allows employers to directly manage and fund workers' compensation claims, rather than paying premiums to the state insurance system.
Who needs to file the Ohio Si 7 form?
Any employer in Ohio who is currently authorized as self-insured for workers' compensation and wishes to renew this status must file the Ohio Si 7 form. This includes corporations, partnerships, LLCs, and public employers that meet specific criteria regarding their financial stability and administrative capabilities.
How often must the Ohio Si 7 form be filed?
The Ohio Si 7 form must be filed annually, prior to the expiration of the current authorization. The specific renewal date is tied to the employer's authorization period and must be adhered to in order to maintain uninterrupted self-insured status.
What information is required on the Ohio Si 7 form?
This form requires detailed information about the employer, including the official corporate name, federal ID number, address, number of Ohio employees, and details of the corporate structure. Additionally, it calls for the submission of financial statements, a list of subsidiary entities in Ohio, information on corporate restructuring, and details regarding the administration of workers' compensation claims, including excess insurance and claims file housing locations.
Can the financial statements be publicly sourced?
Yes, if the employer's financials are public, the Ohio Bureau of Workers' Compensation (BWC) can directly obtain the financial statements from either the employer's website or the SEC. This avoids the need for employers to submit their financial information directly, simplifying the renewal process.
What happens if there is a change in corporate structure or administration?
If there has been a change in the corporate name, structure, or ultimate U.S. parent during the past year, or if the Ohio administrator has changed, detailed explanations and relevant documentation, such as updated organizational charts or Ohio secretary of state papers, must be provided with the Si 7 form.
Is there a certification process for the information provided on the Ohio Si 7 form?
Yes, the form requires certification through a notary public. This entails the corporate officer signing the form, thereby swearing that the information provided is true to the best of their knowledge. This step is crucial for the legal validation of the application and must be completed for the form to be processed.
When completing the Ohio SI-7 form, which is the Application for Renewal of Authorization to Operate as a Self-insured Policy, a number of common mistakes can lead to processing delays or even the rejection of the application. Being aware of these common errors can help ensure a smoother application process.
Not answering all questions: The form explicitly requests that all questions be answered. Leaving a question unanswered, without even marking it N/A for not applicable, can lead to incomplete application status, requiring additional follow-up and potentially delaying the renewal process.
Failing to include all requested documentation: The instructions state that all requests for data and financial statements must be filed; failure to do so will result in the Bureau of Workers' Compensation (BWC) not considering the renewal of self-insurance. Neglecting to attach required documents like the financial statements can halt the application's progress.
Incorrect employer information: The employer name and federal ID number must be shown exactly as they appear in the Articles of Incorporation. Any discrepancies between these documents can raise questions about the applicant's legitimacy and delay the processing of the form.
Not disclosing corporate changes: The form asks whether there have been any changes in corporate name, structure, or the ultimate U.S. parent in the past year. Failure to disclose these changes, and not providing accompanying Ohio secretary of state papers and updated organizational charts, can mislead or confuse the BWC, affecting the renewal process.
Incorrectly listing subsidiary information: Subsidiaries authorized by BWC to operate under the self-insured policy number must be accurately listed with their employer federal ID number, percent of ownership, and employee count. Not listing these entities correctly, or not filing an initial application for those not appearing on your certificate, can affect your coverage.
Omitting excess workers' compensation insurance details: If your company carries excess workers' compensation insurance, you must submit a copy of the policy's declaration page. Neglecting to do so leaves out critical information that the BWC needs to evaluate your self-insurance renewal application comprehensively.
To avoid these common mistakes, it's essential to carefully review the SI-7 form instructions, double-check that all requested information is accurately filled out and included, and ensure that all documentation is attached before submission. Taking these steps can help streamline the renewal process and minimize any potential delays.
Submitting an Ohio SI-7 form, an Application for Renewal of Authorization to Operate as a Self-insured Policy, is a critical step for employers in Ohio who wish to continue managing their workers' compensation responsibilities in-house. Alongside this form, several other documents and forms often play vital roles in ensuring full compliance and operational effectiveness in managing self-insurance. Understanding these additional documents can significantly streamline the renewal process and maintain your company's good standing.
In tandem, these documents complement the SI-7 form, ensuring a comprehensive package is presented to the Ohio Bureau of Workers' Compensation (BWC) for your self-insurance renewal. Each plays a unique role in demonstrating your company's ongoing capability and commitment to responsibly managing workers' compensation claims. Properly organizing and submitting these documents can facilitate a smoother renewal process, helping you avoid any potential for delays or complications.
The Ohio SI-7 form, which focuses on the renewal of authorization to operate as a self-insured policy, bears resemblance to the Annual Report form that businesses typically must file with their respective Secretary of State's office. Similar to the Ohio SI-7 form, the Annual Report also requires detailed information about the company, such as legal name, address, and the number of employees. Both documents serve as confirmations that the business is continuing in compliance with state regulations, ensuring that the company's information is current and accurate for official records.
The Workers' Compensation Exemption form, often used by businesses to declare exemption from traditional workers' compensation insurance requirements, shares similarities with the Ohio SI-7 form in its purpose of altering a company's approach to workers' compensation. Like the SI-7, it necessitates the provision of company specifics and proof of meeting certain criteria to qualify for the exemption. While one focuses on renewing self-insured status, both forms pivot on demonstrating compliance with state-specific workers' compensation laws.
Financial statements required by regulatory bodies, including balance sheets and income statements, also parallel the Ohio SI-7 form in several aspects. These financial documents require detailed reporting of a company's financial health, akin to how the SI-7 form asks for in-depth company information, financial statements, and Ohio assets and payroll details. Both sets of documents are vital for assessing a company's fiscal stability and operational capability, serving as tools for oversight and governance.
Corporate Amendment Forms required for any changes in a business’s legal structure, name, or ownership closely align with certain sections of the Ohio SI-7 form. When a company undergoes restructuring, updates to these forms and the SI-7 are necessary to reflect current information accurately to the state. Both require details on corporate structure changes and updated contact information, ensuring regulatory bodies have the correct data for official records and compliance purposes.
The Compliance Certification forms, which companies may use to declare adherence to specific regulatory requirements, share the purpose of the certification section of the Ohio SI-7 form. This section requires an authorized company representative to swear the completeness and accuracy of the information provided, just as Compliance Certification forms necessitate a declaration of adherence to regulatory standards. Both ensure businesses meet the necessary legal benchmarks to continue operations within their jurisdiction.
When completing the Ohio SI-7 form, it's important to pay close attention to the instructions and details to ensure the application process is smooth and successful. Here's a guide to help you through the process:
What to Do:
What Not to Do:
When it comes to completing the Ohio SI-7 form, which is the Application for Renewal of Authorization to Operate as a Self-insured Policy, there are several misconceptions that can lead to confusion or errors in submission. Understanding these misconceptions is key to ensuring that the renewal process goes smoothly for employers seeking to maintain their self-insured status in Ohio. Below are ten common misconceptions about the Ohio SI-7 form, explained to provide clarity.
Clearing up these misconceptions helps employers navigate the renewal process more effectively, ensuring that all requirements are met for maintaining self-insured status in Ohio. It promotes a greater understanding of the importance of each section of the SI-7 form and the critical role accurate information plays in the renewal application. This not only facilitates a smoother process but also contributes to the efficiency and reliability of worker's compensation management in the state.
When filling out and using the Ohio SI 7 form for the renewal of authorization to operate as a self-insured entity, businesses need to pay attention to several key elements:
This form requires careful attention to detail and accuracy to ensure compliance and avoid delays in the renewal process. Entities must also be aware of any changes in their operations or structure that could affect their self-insured status and communicate these changes promptly to the BWC.
Ohio Liquor License Transfer - Stresses the necessity of a Food Service Operation or Food Establishment License in the applicant's name, aligning with health and safety regulations.
Ohio Guardianship of Minor Child - It includes a section for listing the next of kin of the ward, keeping the court informed about potential contacts in case of the guardian's incapacity or the ward's death.