Lump Sum Settlement (LSS) {BWC-7651}

Lump Sum Settlement (LSS) Direct Reimbursement Rating and Payment Program for Public Employer State Agencies Instructions This LSS Program is available to only those public employer state agencies that are not participating in a settlement payment program. State agencies may choose to participate in the LSS Program on the first day of any quarter. The LSS Program requires a three-year commitment. It's automatically renewable unless you notify BWC that your agency does not want to renew. You must submit an application prior to the first day of the second month of any quarter to be effective the first day of the following quarter. The filing dates are as follows: o File by Feb. 1 to be effective April 1; o File by May 1 to be effective July 1; o File by Aug. 1 to be effective Oct. 1; o File by Nov. 1 to be effective Jan. 1. th Send the completed form to BWC, Actuarial Division, 30 W. Spring St., 25 Floor, Columbus OH 43215. BWC will send a letter of acknowledgement of receipt of this application to the state agency submitting this form. Agency name Address County Email address City Office telephone number Policy number State Nine-digit ZIP code Fax number ( ) ( ) Effective date of participation I affirm the information provided on this form is accurate to the best of my knowledge. I further affirm that I have the authority to sign this application form as a designated executive representative of my agency and that by my signature below I commit my agency to follow all rules and procedures relative to this program. Name of signatory Title of person signing Signature of designated executive staff Date BWC-7651 (Rev. March 4, 2014) U-145 American LegalNet, Inc. www.FormsWorkFlow.com