V+A Risk Services is an Ohio based TPA for workers’ compensation claims management services. We are proud of our heritage and have stood ready to serve our valued clients since 1974. As a locally based company, we fully understand Ohio’s complex regulations and provide expert guidance as trusted advisors.
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| Renewal Form |

Thank you for coming to our Group Experience Rating Program renewal page. For your convenience you can renew here today to make sure you do not miss out on the workers’ compensation premium savings. Our filing deadline is November 20, 2017.
Please indicate the following:
(found in the packet we mailed to you)
 YesPlease renew my policy into the V&A Group Experience Rating Program for the July 2018 rating year.
 YesI have read & agree to the terms of the Group Experience Rating Participation Agreement and the Employer Administrative Services Agreement (included in your packet and available here by clicking on the form name.)

If future data received from BWC changes the information we based this renewal upon you will be contacted and your renewal may be revoked. This would only happen in extreme circumstances and we would contact you to make sure the BWC has properly processed the change.

1. Is your company a professional employer organization (PEO) or have you used the services of a PEO in the last 5 years?*
2. Has your company acquired or merged with another company in the last 5 years?*
3. Has your company closed an existing policy and re-opened under another policy?*
4. Has your company been audited by BWC during the past 5 years or are you currently undergoing an audit?*
- If yes, did the audit result in a change in manual classification?*
- Did the audit result in penalties or a change in how you report your payroll?*
5. Are there any issues pending an adjudication hearing with the BWC?*
6. Does this company, or any of its owners, own or operate any other entities in the State of Ohio under different BWC policies?*
- If yes, list name & policy number
7. Have you reported your payroll to another company or another unit of your company or has BWC reassigned all or part of your payroll to another company or another unit of your company?*
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