Step-by-step instructions to complete the U-21
Public employers

1. You must include both your federal identification and policy numbers on this form.
2. Enter your company name and telephone number. Also, enter city, state and nine-digit ZIP code.
3. Retrospective rating plan parameter selections: You must select one of the following retrospective rating plan parameters. Your selection will determine the minimum and maximum level, as well as the exposure to claims losses. Choose one claim limit and one maximum premium limit from the following Tier I parameters:
   
   Tier I parameters
   
   
   • Claim limit: $200,000, $300,000, $400,000, no claim limit;
   • Maximum premium: 150 percent or 200 percent.
   
   
   Tier II parameters

   If you do not meet the requirements for Tier I do you want to be considered for Tier II?
   
   If so, choose one of the following claim limits: $100,000 or $125,000. Tier II offers a maximum premium of 150 percent.
   
   Tier II eligibility requirements are the same as Tier I except if you have entered into any partial payment arrangements with BWC, this will not preclude you from being considered for retrospective rating.

4. Estimated policy year payroll - Provide estimated payroll you will report during the policy year for each manual classification assigned to your policy number. The public taxing district policy year is Jan. 1 to Dec. 31.

   Use National Council on Compensation Insurance (NCCI) manual classification numbers or BWC will reject your application.

5. Payroll rounded to the nearest thousand dollars (List all NCCI manual classifications below)

   NCCI	Payroll	NCCI	Payroll	NCCI
   Manual number		Manual number		Manual number
   *You can access additional pages if necessary for manual classifications

   Owner partner officer
   
   
   1. Statement of agreement: I have read the retrospective rating rules in their entirety. I understand the rules and agree with the terms of the retrospective rating plan.
   2. Note: BWC must review and approve the application before it becomes effective. BWC will notify you in writing when the application is approved and the applicable minimum premium percentage.
      
      * If you are applying for the first time, you must submit five years of audited financial information. If you are reapplying, you only need to submit the previous year’s audited financial statement. Mail this information within five calendar days to:
      
      BWC
      Employer programs
      30 W. Spring St., 22nd floor
      Columbus, OH 43215-2256