CLEAN_BWC_Certificate_4.21.25.pdf

Mike DeWine, Governor Jim Tressel, Lt. Governor Stephanie McCloud, Administrator/CEO

1-800-644-6292 BWC.Ohio.govBureau of Workers' Compensation

30 West Spring Street Columbus, Ohio 43215-2256

#BWNFVSQ

#XX10028677195#

04/21/2025 Date Mailed .Invisible_TemplateName=DP29Delivery_Channel=mailInvisible_Document_Date=2025-04-21Invisible_ClaimNumber=undefinedInvisible_PolicyNumber =80177721Invisible_Recipient=Clean Enterprises Ltd.Invisible_AddressLine1=4182 Worth AveInvisible_AddressLine2=undefinedInvisible_City=ColumbusInvisible_State =OHInvisible_zip =43219-1535Invisible_Country=United StatesInvisible_Document_Context =PolicyInvisible_Watermark_Name =\\mswg9\CoreSystem\PP\ALC\Images\blank.tifInvisible_Creator_Name =BATCH Invisible_Participation_Type =InsuredInvisible_QuoteNumber =undefinedInvisible_FEIN =undefined

Clean Enterprises Ltd.

4182 Worth Ave Columbus OH 43219-1535

IMPORTANT DOCUMENT: REMOVE AND POST

DP-29 BWC-1629 (Rev. Jan. 10, 2019)

30 W. Spring St.

Columbus, OH 43215

Certificate of Ohio Workers' Compensation This certifies that the employer listed below participates in the Ohio State Insurance Fund as required by law.

Therefore, the employer is entitled to the rights and benefits of the fund for the period specified. This certificate is only valid if premiums and assessments, including installments, are paid by the applicable due date. To verify coverage, visit www.bwc.ohio.gov, or call 1-800-644-6292.

This certificate must be conspicuously posted.

Policy number and employer 80177721

Period Specified Below 07/01/2025 to 07/01/2026

Clean Enterprises Ltd.

4182 Worth Ave Columbus OH 43219-1535 www.bwc.ohio.gov Issued by: BWC

Administrator/CEO You can reproduce this certificate as needed.

Ohio Bureau of Workers' Compensation

Required Posting

Section 4123.54 of the Ohio Revised Code requires notice of rebuttable presumption. Rebuttable presumption means an employee may dispute or prove untrue the presumption (or belief) that alcohol, marihuana or a controlled substance not prescribed by the employee's physician is the proximate cause (main reason) of the work-related injury.

The burden of proof is on the employee to prove the presence of alcohol, marihuana or a controlled substance was not the proximate cause of the work-related injury. An employee who tests positive or refuses to submit to chemical testing may be disqualified for compensation and benefits under the Workers' Compensation Act.

You must post this language with the Certificate of Ohio Workers' Compensation.

Policy Information

Policy Information for the policy period beginning from 12:01 AM on 07/01/2025 to 12:01 AM on 07/01/2026.

Policy Number and Employer MCO

80177721 Clean Enterprises Ltd.

4182 Worth Ave Columbus OH 43219-1535

No MCO has been selected

Additional Insured’s Name and Address Effective Date Expiration Date

Individuals Eligible for Elective Coverage Individuals Eligible for Elective Coverage Covered (Yes/No) Elective Coverage Type

No Elective Individuals.

**Please refer to our website for reporting guidelines/requirements.

Corporate Officer Effective Date Expiration Date

ANTONIO SMITH 07/01/2025 07/01/2026

**Please refer to our website for reporting guidelines/requirements.

Employee Class Codes and Descriptions Class Code Class Code Description

8868 COLLEGE-PROFESSIONAL EMPLOYEES & CLERICAL

The information noted above is as of 04/19/2025. For the most current information on the policy or to update your account information, please log into your account at www.bwc.ohio.gov. You may also call 1-800-644-6292 to speak with a customer service representative.