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BWC Group Rating 2020 Enrollment Form

BWC Group Rating 2020 Enrollment Form

Thank you for your interest in the Paramount Preferred Solutions, Inc. and Ohio Group Management Group Rating program.

Please fill out the form below to re-enroll in the group plan and submit a payment on your account.

*Denotes a required field

General Information

BWC Policy Number
Company Name
Contact Name
Title
Email

Group Profile Form - 2020 Group Rating Program

We cannot process online Renewal Forms for Professional Employer Organizations (PEO's)
If you answer YES to Question 1, Please STOP this form and Call one of our customer service representatives at 866.302.2667

1) Is your company a Professional Employer Organization (PEO) or been affiliated with a PEO in the past 2 years?
 Yes  No
2). In the past 5 years did your company restructure, purchase, merge, or acquire the assets of another Ohio Company?
 Yes  No
If yes, please list the Ohio BWC Policy Number and Entity Name
3). In the past 5 years, has your company done business in Ohio under another BWC policy, other than the one your are enrolling in this plan?
 Yes  No
If yes, please list the Ohio BWC Policy Number and Entity Name
4). Does your company currently have a BWC matter pending before the Court of Common Pleas, the Court of Appeals or the Ohio Supreme Court?
 Yes  No
5). In the coming 18 months, does your company plan to acquire all or part of another Ohio operation or the assets of another Ohio entity?
 Yes  No

Payment Information

Payment Amount

*Please enter payment amount excluding the dollar signs ($) and commas (,)

Credit Card Type
Name on Card
Credit Card Number
Card Expiration
CVV
Payment Notes

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move


 

By clicking the 'Submit' button below, you are agreeing to the terms of the Group Rating Participation Agreement included in your enrollment packet.  A copy of that agreement is included in the link above.  Thank you for choosing PPS, we appreciate your business.

Please only click submit once. The form may take up to 10 seconds to submit.