Request For Business Transfer Information {BWC-0504}

Request for Business Transfer Information 1. Purpose This form is to be used to obtain information from BWC concerning (1) the rates to be applied where one employer takes over the occupation or industry of another, and (2) the portion of the account assumed by the successor in interest. The release below must be signed by the employer that may be transferred in whole or in part, as well as the employer that may acquire the transferred business. The release must be validated by BWC, and a copy produced by the employer or its representative requesting business transfer information. Please submit the completed form to: Employer Services 30 W. Spring St., 22nd Floor Columbus, Ohio 43215-2256 Fax: 614-728-0456 2. Limited Release The signatures below certify that (business that may be transferred) ____________________________________ grants permission to (acquiring entity) ________________________________, including its agents or representatives, to review and perform studies on certain workers' compensation information associated with the policy of (business that may be transferred) ______________________ listed below. NOTE: The information that may be released as a result of presenting this document to BWC is current only as of the date it is produced, and does not reflect any changes, adjustments or audits that may be currently in process. BWC cannot guarantee the accuracy of this information beyond the date of production. This limited release provides access to the following information relating to the workers' compensation policy of the business that may be transferred: o Employer Demographic Information o Experience Modification History o Account Receivable Balance o Most recent Quarterly Claim Cost Summary o Payroll History o Current Premium Audit Pending? Yes No This authorization is limited and temporary in nature and will expire on _____________, or automatically 30 days from the date signed by the representative of the business that may be transferred. In no case shall the length of authorization exceed 30 days. 3. Policy Information and Signatures Entity Granting Access to Information (Business that may be transferred) Policy number Entity name Email address Name (please print) Title Signature Date Entity Requesting Access to Information (Acquiring Business) Policy number (if applicable) Entity name Email address Phone number Name (please print Title Signature Date Completion of this disclosure form provides an employer that is contemplating or is in the process of completing a purchase, acquisition, merger or other transfer of an existing business limited authority to view payroll and loss experience of the business that may be transferred. By signing the AC-4, the employer whose business may be transferred grants permission to the BWC to release policy information to the acquiring business and its authorized representative(s). BWC-0504 (Rev. July 29, 2015) AC-4 American LegalNet, Inc. www.FormsWorkFlow.com