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Application for Retrospective Rating Plan
Private Employers (U-20); Public Employers (U-21)
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Introduction to retrospective rating |
The retrospective rating plan is an alternative rating plan that allows the employer
to initially pay BWC less premium than it would without the plan.
An employer participating in the retrospective rating plan may earn a possible premium
reduction by assuming a portion of the risk. The greater the portion of the risk
assumed, the greater potential reduction in premiums.
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| Additional information |
Program info
Eligibility requirements
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| Required information |
- Policy mumber
- Tier type consideration
- Claim limit
- Maximum premium
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- Owner/Party/Officer name
- Owner/Party/Officer title
- Owner/Party/Officer signature
- Payroll amount
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| Complete the forms |
The free Adobe Reader
software is required to display and print the application.
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You may print a blank copy of the U-20 or U-21 to complete by hand and
either mail or fax it to BWC.
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Do you have all the required information at hand? If so, you are ready to begin
completing the form.
I have been authorized to sign and execute this application for the retrospective
rating plan on behalf of the company.
I have read and understand the retrospective rating plan rules
(
4123-17-41 to 4123-54 of the Administrative Code for Public Sector Employers,
or
4123-17-41 to 4123-53 of the Administrative Code for Private Sector Employers)
in their entirety and agree to comply with the terms of the retrospective rating plan,
including payment of the annual claims billings in accordance with the plan and the
governing rules.
Begin online form now.
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If you need additional assistance, please contact BWC's retrospective rating unit at (614) 466-6773
or e-mail the unit.
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