Application For Exemption From Ohio Workers Coverage And Waiver Of Benefits {BWC-7614}

BWC-7614 - APPLICATION FOR EXEMPTION FROM OHIO WORKERS’ COVERAGE AND WAIVER OF BENEFITS. The employer is applying for exemption from paying BWC compensation premiums or assessments in respect to each employee completing Section III of this form. This includes self-insuring employers paying compensation and benefits directly. This exemption does not relieve the employer from the obligation to pay the applicable minimum administrative charge. The employer certifies he or she has informed each employee completing Section III of this form that he or she is waiving the right to receive workers’ compensation benefits. In addition, the employer and employee must complete and have notarized the attached affidavits and return them with the U-3E application. If there are multiple employees, additional copies may be made. The employer agrees to notify BWC within 30 days of any occurrence that results in the employer no longer being designated as a member of the religious group described below, or that the employer no longer follows the established teachings of this group. From that date forward, the employer will be responsible for all premiums and assessments. This includes self-insuring employers paying compensation and benefits directly. U-3E. www.FormsWorkflow.com