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Ohio Laws and Rules
(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)
Employee Representatives Employer Representatives
Name Title Name Title
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:
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