Get 6165con

Filling out the 6165con form is essential for employers who want to obtain workers' compensation coverage from states other than Ohio. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the online 6165con form.

1. Press the ‘Get Form’ button to access the form online and open it for editing.
2. Enter the employer information in the designated fields, including your name, BWC policy number, street address, phone number, city and state, fax number, zip code, and email address.
3. Provide the other state's insurance information by filling in the insurer's name, insurance policy number, street address, effective date of the policy, city and state, and zip code.
4. If there are multiple insurers for different states, make sure to provide the additional insurer information as needed by repeating the previous step.
5. In the certification section, ensure that you certify the information provided is accurate and that you have the authority to notify BWC of this election. Include your signature, title, printed name, date, telephone number, and email address.
6. Once all sections are completed and verified for accuracy, save your changes. You can then download, print, or share the completed form as required.

Complete your 6165con form online today to ensure compliance and effective coverage!