An Ohio resident employee who is employed by an Ohio based employer may work in another state some or all the time. This leads to the possibility that Ohio’s workers’ compensation laws may conflict with those of the other state. In these cases, Ohio law allows employers and employees to choose workers’ compensation coverage from Ohio or from the other state. By acknowledging and submitting this form, both the employee and employer agree to be bound exclusively by the workers’ compensation laws of Ohio.The parties to this agreement represent to BWC that there is a possibility of a conflict between the workers’ compensation laws of Ohio and those of another state, because the employee will perform all or some of the work in a state or states other than Ohio. The state(s) in which the employee will travel to or through is (are) OH, WV, KY, MI, IN, PA, NY. Under Ohio Revised Code Section 4123.54, the employer and employee agree to be bound exclusively by the workers’ compensation laws of Ohio. Regardless of where a work-related injury or death occurs or where an employee contracts an occupational disease, the workers’ compensation laws of Ohio and not the laws of another state will govern the rights of the employee and his or her dependents. Employee thereby waives any right to file a claim for a work-related injury in any state other than Ohio.  This agreement shall remain in effect until the parties terminate or modify it by entering into a new agreement. In case of emergency, Call 911 - it is always our priority for you to seek care immediately regardless of state. Employee Name: