Chapter 4167-15 Exemption Application

4167-15-01 Exemption application requirements.

(A) Pursuant to the application (see appendix to rule 4167-15-01 of the administrative code) the public employer must provide:

(1) Its bureau of workers' compensation risk number;

(2) If a member of a group, the name of the sponsoring association and or service representative;

(3) If not a member of a group, a copy of its current workers' compensation experience (actuarial) exhibit;

(4) A copy of the ordinance or resolution requesting an exemption.

(B) The certification must be made by the elected official(s) of the public employer requesting the exemption.

Appendix A

Ohio Bureau of Workers' Compensation

Public Employment Risk Reduction Act

Application for Exemption

1. Public Employer: ___________________________________

Address: _________________________________________________

_________________________________________________

City: _______________ Zip: _______ County: __________

Contact: ____________________ Title: _______________

Phone: ____________________ Fax: _______________

2. BWC Risk No.: PE-____________________ 3. No. of employees: _____

4. Are you a member of a group rating plan pursuant to division (A)(4) of section 4123.29 of the Revised Code?

____yes ____no

a. If yes, please provide the name of your:

Sponsoring association: ____________________

Service representative: ____________________

b. If no, please attach a copy of your current workers' compensation experience (actuarial) exhibit.

c. If you do not qualify for a group rating plan, provide the names and titles of the members of your safety committee. Attach a separate sheet, if necessary. (Not required of employers with five or fewer employees)

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Employee Representatives Employer Representatives

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Name Title Name Title

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I,_______________________________, certify that the following statements are true:

Name of applicant(please print)

1. The public employer has adopted an ordinance or a resolution, dated __________, requesting an exemption from Chapter 4167 of the Revised Code. (Please attach a copy.)

2. At least ten days prior to the passage of the ordinance or resolution, the public employer informed its public employees of this application by giving a copy of the application to its public representative, if any.

a. Name of public employee representative: _________________________

b. Date notified: __________

3. The public employer has informed its public employees by posting a statement, for thirty consecutive days at the place or places where notices to public employees are normally posted and by any other appropriate means of public employee notification, giving a summary of this application and specifying where a copy of this application may be examined. Dates of posting: From _______ to _______

4. The public employer has informed its public employees of their rights to a hearing under section 4167.15 of the Revised Code.

Describe briefly how the public employees have been informed of this application and of their rights to a hearing:

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______________________

Signature of Applicant

_____________________

Title

Sworn to before me and subscribed in my presence this _____ day of __________, 19__

(SEAL) ________________________________________

Notary Public

My commission expires _______________

Effective: 02/15/2009
R.C. 119.032 review dates: 10/24/2008 and 10/01/2013
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4167.02, 4167.07
Rule Amplifies: 4167.19
Prior Effective Dates: 11/15/96

4167-15-02 Exemption may be revoked.

The administrator may revoke an exemption under the following circumstances:

(A) If the employer does not comply with division (I) of section 4167.19 of the Revised Code.

(B) If pursuant to an inspection pursuant to division (G) or (I) of section 4167.19 of the Revised Code or section 4167.06 of the Revised Code, the administrator finds hazardous or unsafe conditions.

Effective: 02/15/2009
R.C. 119.032 review dates: 10/24/2008 and 10/01/2013
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4167.02
Rule Amplifies: 4167.19
Prior Effective Dates: 1/17/99