Employer Authorized Representative Instructions · TheemployerandrepresentativemustcompletethisformandfileitwithBWC. · YoumustpossessavalidBWCrepresentativeIDnumber. · ToobtainavalidrepresentativeIDnumber,contacttheCentralOffice,customerassistancedeskat614-466-1958 or614-466-1563,orinquireatanyBWCcustomerserviceofficeinformationdesk. Injured worker name Claim number Date of injury Employer policy number Employer name Employer address City, State, ZIP code Representative Representative name Representative ID number Address Telephone number City, State, ZIP code Representative e-mail address Fax number Authorization I hereby authorize the above representative to represent me in the above claim before the Ohio Bureau of Workers' Compensation and the Industrial Commission of Ohio. This authorization also entitles this representative to automatically receive correspondence generated in the above claim file. Signature of employer official granting this authorization X Date of authorization BWC-6101 (8/14/2008) R-1 American LegalNet, Inc. www.FormsWorkFlow.com