Non Ohio Amended Payroll Report {BWC-7653}

Non-Ohio Amended Payroll Report Instructions You must complete this form in its entirety along with a reason for the change. Only include payroll for duties performed outside of Ohio and payroll reported to the other states insurer. Policy number Legal business name Mailing address City Trading name or doing business name Email address State Telephone number ( ) ZIP code Payroll period From through Insured state Payroll (rounded to the nearest dollar) Reason for change Certification I hereby certify the amended non Ohio payroll reported herein is correct as to insured state and payroll amount for the period stated. I understand that misrepresenting payroll will make me non compliant for having other states coverage with regard to Section 4123.292 of the Ohio Revised Code. By my signature, I certify I have the authority to execute this document, and that the facts set forth on this document are true and correct to the best of my knowledge and belief. I am aware that any person who does not secure or maintain workers' compensation coverage and pay all appropriate premiums in accordance with Ohio laws, or misrepresents, conceals facts or makes false statements to obtain coverage may be subject to civil, criminal and/or administrative penalties. Signature and title (must be signed by owner, partner or officer) Date BWC-7653 (Rev. 10/26/2011) U-147 American LegalNet, Inc. www.FormsWorkFlow.com