Comprehensive Risk Management : Online AC-3 Form

TEMPORARY AUTHORIZATION TO REVIEW INFORMATION

NOTE: All fields in bold are required.

From: Policy Number
Entity
DBA
Address
City
State
ZIP Code

NOTE: For this to be a VALID form, it must be stamped by the Self-Insured Department for self-insured employers or by the Employer Services Division for all employers other than self-insured. This authorization, being temporary in nature, will not be recorded via computer or be retained by the Risk Technical Services Department. A copy must be in the possession of a representative when requesting service relative to the authority granted therein.

This is to certify that Comprehensive Risk Management including its agents or representatives identified to you by them, has been retained to review and perform studies on certain Workers' Compensation matters on your behalf.

This limited letter of authority provides access to the following types of information relating to our account:

Risk files
Claim files
Merit-rated or non-merit rated experiences
Other associated data

This authorization does NOT include the authority to:

Review protest letters
File protest letters
File form CHP-4
File motions, I-12's or IC-88's
File self-insurance applications
Represent the employer at hearings
Pursue other similar actions on behalf of the employer

I understand that this authorization is limited and temporary in nature and will expire on June 1, 2010 or automatically nine months from date received by the Employer Services Division or Self-Insured Department, whichever is appropriate. In either case, the length of authorization will not exceed nine months.

Telephone Number	Fax Number	Email Address
() - Ext.	() -

By checking this box, I certify that I have carefully read all of the above rules of the Ohio Bureau of Workers’ Compensation, and am allowing the bureau to release information regarding my company’s payroll, claims and experience modification to Comprehensive Risk Management, Inc. as allowed by this AC-3 form.

Typing your name here constitutes an electronic signature:

Name	Title	Date
		3/10/2010


Has the above company been involved in employee leasing in the past 5 years?	Yes	No
Was the above company purchased from another entity in the past 5 years?	Yes	No
Was the above company combined with another entity in the past 5 years?	Yes	No

Attention Private Employer 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 who have made application for the next group-rating year if they will not be accepted. The deadline for this notification is December 1st of each year.
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 Employer Services Division. Public employers interested in group-rating programs should contact a group sponsor/TPA for specific information on this program.

	By clicking on the SEND FORM button, I certify that the information completed on the AC3 temporary authorization is accurate; that I am the individual indicated above; and that I have authorization to sign this authorization form on behalf of the Company/Policy indicated on the AC3.