en-USNote:en-US For this to be a en-USvaliden-US letter, the employer services department, or the self-insured department for self-insuring employers, must stamp it.en-USThis is to certify that effective en-US(Date)en-US,en-US(Representative name and rep ID number)en-USIncluding its agents or representatives identi037ed to you by them, has been terminated or retained to represent us before the Ohio Bureau of Workers' en-USCompensation and the Ohio Industrial Commission in matters pertaining to our participation in the workers' compensation fund according to the type of en-USrepresentation checked below.en-USPlease check only one type of representation. See description of representatives at the bottom of this form. en-US037036en-USType of authorized representation addition/change or termination en-USAdd en-USTerminate en-USEmployer-risk claim representative (ERC) en-USRisk-management representative (RISK) en-USClaim-management representative (CLM) en-USPayroll service vendor (PSV)en-USThis authorization supersedes all permanent authorizations on 037le for the type of representation indicated above.en-USI understand and agree BWC will process any letters, requests and actions initiated by a superseded authority.en-USI understand this authorization, now being granted, is of a continuous nature from the effective date indicated herein. However, I possess the right to en-USterminate this authorization at any time through written noti037cation to the employer services or self-insured departments as appropriate. en-USTelephone numberen-USFax numberen-USEmail addressen-USPrint name and titleen-USEmployer signatureen-USDateen-USBWC authorized representative service/rolesen-USEmployer-risk claim representative (ERC)en-US 226 The ERC is designated as the employer222s authorized representative for both risk- and claims-management-related issues. He en-USor she is also the employer222s authorized representative on each claim under the employer222s policy number. The ERC receives copies of all risk and claim correspondence. en-USThe ERC has full access to the employer222s risk information and information pertaining to the workers222 compensation claims 037led against the employer. He or she will also en-UShave the authority to access such information on www.bwc.ohio.gov.en-USBWC will consider the ERC as the authorized representative in handling risk-related issues for an employer if there is no designated group-risk claim representative (GRC). en-USBWC also will consider the ERC as the authorized representative in handling claim-related issues for an employer if there is no designated CLM or GRC.en-USRisk-management representative (RISK) en-US226 The RISK is the employer222s designated authorized representative for risk-related issues. He or she represents an employer en-USon risk-related issues only. The RISK receives copies of all risk correspondence. A RISK will have access to only the employer222s risk-related information and authority to en-USaccess that information on www.bwc.ohio.gov.en-USBWC will consider the RISK as the authorized representative in handling risk-related issues for an employer if there is no designated GRC or ERC. The RISK will have no en-USauthority to represent the employer on any matters if either a GRC or ERC is appointed. In addition, the RISK will have access only to the employer222s risk-related information en-USand authority to access that information on www.bwc.ohio.gov.en-USClaims-management representative (CLM)en-US 226 The CLM is the employer222s designated authorized representative on each claim associated with the employer. He or she will en-USreceive copies of all claim correspondence. The CLM represents an employer on claim-related issues only. A CLM will have access only to information pertaining to the en-USworkers222 compensation claims 037led against the employer and authority to access that information on www.bwc.ohio.gov.en-USBWC will consider the CLM the authorized representative in handling claims-related issues for an employer.en-USPayroll service vendor (PSV)en-US 226 A payroll service vendor provides payroll services, including reporting and/or withholding and remittance services for workers222 compensaen-US-en-UStion premium payments.en-USNote: en-USBased on the designation made by the group222s sponsor, only the employer services group-rating unit can update a GRC.en-USYou cannot use the AC-2 to select a GRC authorization. This representative type only applies to private employers and public employer taxing districts. BWC will consider en-USthe GRC the authorized representative in handling risk-related issues for an employer. In addition, BWC will consider the GRC the authorized representative in handling en-USclaim-related issues for an employer if there is no designated claims-management representative (CLM).en-USBWC-0502 (Rev. Nov. 5, 2018)en-USAC-2 en-USPolicy numberen-USDBAen-USAddressen-USEntity To: þ Ohio Bureau of Workers' Compensation en-US Employer Services Department, 22en-USnd en-US036oor en-US Self-Insured Department, 22en-USnd en-US036ooren-USPlease mark a box and return to:en-US30 W. Spring St.en-USColumbus, OH 43215-2256en-USFax: 614-621-1405en-USRequest to Add/Change or Terminate en-USPermanent Authorization Spanish speaking ~ online form American LegalNet, Inc. www.FormsWorkFlow.com