Form U-131 (BWC-7637) "Notice of Election to Obtain Coverage From Other States for Employees Working Outside of Ohio" - Ohio

What Is Form U-131 (BWC-7637)?

This is a legal form that was released by the Ohio Bureau of Workers' Compensation - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Ohio Bureau of Workers' Compensation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form U-131 (BWC-7637) by clicking the link below or browse more documents and templates provided by the Ohio Bureau of Workers' Compensation.

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Download Form U-131 (BWC-7637) "Notice of Election to Obtain Coverage From Other States for Employees Working Outside of Ohio" - Ohio

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Notice of Election to Obtain Coverage
from Other States for Employees
Working Outside of Ohio
Please read this information before completing the form.
• Mail both documents to: BWC Policy Processing Department,
30 W. Spring St., 22nd Floor, Columbus, OH 43215.
This information concerns only employees who work outside of
Ohio on a temporary basis. Ohio law allows employers to obtain
Payroll reporting and premium payment requirements
coverage in other states in addition to their Ohio coverage. (Ohio
Employers electing coverage from another state:
Revised Code (ORC) 4123.292)
• Must report payroll and pay premium to BWC for all work their
• Ohio coverage applies to work performed temporarily in
employees do in Ohio;
another state if the claim is filed with BWC.
• Should NOT include work done outside of Ohio when reporting
• However, the employer may elect to obtain workers‘ compen-
payroll or calculating premium payments to BWC;
sation coverage from an authorized insurer in the state which
• Must report payroll for work done outside of Ohio to BWC on a
he or she performs work. (NOTE: Depending upon the law of
separate form. (This is for record-keeping purposes only since
the other state, it may require the employer to obtain cover-
they do NOT have to pay an Ohio premium for out-of-state
age in that state.) This other state‘s coverage applies to only
work.);
work done outside of Ohio.
• Must both report and pay premium for any work done outside
• This selection allows the employer to segregate payroll
of Ohio to the other state or insurance company providing the
reported to the other states insurer for work done outside
coverage.
Ohio from their Ohio payroll reported to BWC.
Employer’s notification to BWC
How to meet the notification requirement
This certifies that the employer listed below has elected coverage
Employers electing coverage from another state must: (1) notify
from an insurer other than BWC for work done outside of Ohio. The
BWC in writing; (2) give BWC the name of the state agency or insur-
employer is submitting this form along with a copy of his or her insur-
ance company providing the coverage.
ance policy from the other state where work occurs. This shows proof
• Complete this form and return it to BWC to meet these
of workers’ comp coverage from an authorized insurer. The employer
requirements.
will immediately notify BWC in writing of cancellation of this policy for
• Include a copy of the insurance policy as proof of coverage
any reason.
from the other state.
Employer information
Employer name
BWC policy number
Street address
Phone number
City and state
Fax number
Zip code
E-mail address
Other-states’ insurance information
Insurer name
Other-state’s insurance policy number
Street address
Effective date of policy
City and state
Zip code
Insurer name
Other-state’s insurance policy number
Street address
Effective date of policy
City and state
Zip code
Certification
I certify this employer has elected to obtain workers’ comp coverage from an authorized insurer other than BWC for work done outside of Ohio.
I also certify I have the authority to notify BWC of this election. My signature indicates the statements on this form are true to the best of my
knowledge. I am aware that anyone who makes false statements, conceals facts or misrepresents payroll to BWC may be subject to civil, criminal
and administrative penalties.
Signature of owner, partner, member, or executive officer
Title
Printed name of above signature
Date
Telephone number
E-mail address
BWC-7637
U-131
Notice of Election to Obtain Coverage
from Other States for Employees
Working Outside of Ohio
Please read this information before completing the form.
• Mail both documents to: BWC Policy Processing Department,
30 W. Spring St., 22nd Floor, Columbus, OH 43215.
This information concerns only employees who work outside of
Ohio on a temporary basis. Ohio law allows employers to obtain
Payroll reporting and premium payment requirements
coverage in other states in addition to their Ohio coverage. (Ohio
Employers electing coverage from another state:
Revised Code (ORC) 4123.292)
• Must report payroll and pay premium to BWC for all work their
• Ohio coverage applies to work performed temporarily in
employees do in Ohio;
another state if the claim is filed with BWC.
• Should NOT include work done outside of Ohio when reporting
• However, the employer may elect to obtain workers‘ compen-
payroll or calculating premium payments to BWC;
sation coverage from an authorized insurer in the state which
• Must report payroll for work done outside of Ohio to BWC on a
he or she performs work. (NOTE: Depending upon the law of
separate form. (This is for record-keeping purposes only since
the other state, it may require the employer to obtain cover-
they do NOT have to pay an Ohio premium for out-of-state
age in that state.) This other state‘s coverage applies to only
work.);
work done outside of Ohio.
• Must both report and pay premium for any work done outside
• This selection allows the employer to segregate payroll
of Ohio to the other state or insurance company providing the
reported to the other states insurer for work done outside
coverage.
Ohio from their Ohio payroll reported to BWC.
Employer’s notification to BWC
How to meet the notification requirement
This certifies that the employer listed below has elected coverage
Employers electing coverage from another state must: (1) notify
from an insurer other than BWC for work done outside of Ohio. The
BWC in writing; (2) give BWC the name of the state agency or insur-
employer is submitting this form along with a copy of his or her insur-
ance company providing the coverage.
ance policy from the other state where work occurs. This shows proof
• Complete this form and return it to BWC to meet these
of workers’ comp coverage from an authorized insurer. The employer
requirements.
will immediately notify BWC in writing of cancellation of this policy for
• Include a copy of the insurance policy as proof of coverage
any reason.
from the other state.
Employer information
Employer name
BWC policy number
Street address
Phone number
City and state
Fax number
Zip code
E-mail address
Other-states’ insurance information
Insurer name
Other-state’s insurance policy number
Street address
Effective date of policy
City and state
Zip code
Insurer name
Other-state’s insurance policy number
Street address
Effective date of policy
City and state
Zip code
Certification
I certify this employer has elected to obtain workers’ comp coverage from an authorized insurer other than BWC for work done outside of Ohio.
I also certify I have the authority to notify BWC of this election. My signature indicates the statements on this form are true to the best of my
knowledge. I am aware that anyone who makes false statements, conceals facts or misrepresents payroll to BWC may be subject to civil, criminal
and administrative penalties.
Signature of owner, partner, member, or executive officer
Title
Printed name of above signature
Date
Telephone number
E-mail address
BWC-7637
U-131