Fields in RED are required.

This is to certify that Associated Compensation Resources (I.D. # 001511-80) including its agents or representatives identified to you by them, has been retained to review and perform studies on certain workers’ compensation matters on our behalf.

The limited letter of authority provides access to the following information relating to your policy:

This authorization does NOT include the authority to:

I understand that this authorization is limited and temporary in nature and will expire on March 1, 2011

or automatically nine months from the date received by the Risk Technical Services Department or Self-Insured Department, whichever is appropriate. In either case, the length of authorization will not exceed nine months.

Signature:   (Typing name below constitutes an electronic signature).

Completion of the Temporary Authorization (AC-3) allows a third-party administrator (TPA) limited authority to view an employer’s payroll and loss experience. By signing (form AC-3), the employer grants permission to the Ohio Bureau of Workers’ Compensation (BWC) to release information to the employer’s authorized representative(s). The Temporary Authorization form allows a third-party representative to view an employer’s information regarding payroll, claims and experience modification.

Attention Group-Rating Prospects:

Employer may complete the AC-3, for as many TPA or group-rating sponsors as they feel are necessary to obtain quotes for a group-rating program.

Group Sponsors must notify all current group members if they will not be accepted for the next group-rating year. The deadline for this notification is prior to the first Monday in February for Private Employers and prior to the second Friday in August for Public Employers.

All potential group-rating prospects must have:

Active BWC coverage status as of the application deadline; Active coverage from the application deadline through the group-rating year; No outstanding balances; Operations similar in nature to the other members of their group.

Any changes to a group member’s policy will affect the group policy. Changes can result in either debits or credits to each of the members.

Note: For complete information on rules for group rating, see Rules 4123-17-61 through 4123-17-68 of the Ohio Administrative code or your third-party administrator (TPA).  All group-rating applicants are subject to review by the BWC Risk Technical Services Department.