Temporary Authorization to Review Information To: Ohio Bureau of Workers' Compensation Employer Services Department, 22nd Floor Self-Insured Department, 22nd Floor Please mark a box and return to: 30 W. Spring St. Columbus, Ohio 43215-2256 From: Policy number Entity DBA Address Note: For this to be a valid letter, the self-insured department for self-insured employers, or the employer services department for all other employers, must stamp it. Being temporary in nature, BWC will not record via computer or retain this authorization. Representative must possess a copy when requesting service relative to the authority granted therein. This is to certify that , 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 types of information relating to our account: 1. Risk files; 2. Claim files; 3. Merit-rated or non-merit-rated experiences; 4. Other associated data. This authorization does not include the authority to: 1. Review protest letters; 2. File protest letters; 3. File form Application for Handicap Reimbursement (CHP-4); 4. Notice of Appeal (IC-12) or Application for Permanent Partial Reconsideration (IC-88); 5. File self-insurance applications; 6. Represent the employer at hearings; 7. Pursue other similar actions on behalf of the employer. I understand this authorization is limited and temporary in nature and will expire on or automatically nine months from the date received by the employer services or self-insured departments, whichever is appropriate. In either case, the length of authorization will not exceed nine months. Telephone number Fax number Email address Print name Title Signature Date Completion of the temporary authorization provides a third-party administrator (TPA) limited authority to view an employer's payroll and loss experience. By signing the AC-3, the employer grants permission to the BWC to release information to the employer's authorized representative(s). The form allows a TPA to view an employer's information regarding payroll, claims and experience modification. Attention group rating prospects · Employers may complete the AC-3 for as many TPAs or group-rating sponsors they feel are necessary to obtain quotes for a group-rating program. · Group sponsors must notify all current group members if they will not accept them for the next group-rating year. The deadline for this notification is prior to the last business day in October for private employers and prior to the last business day in April 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 TPA. All group-rating applicants are subject to review by the BWC employer programs unit. BWC-0503 (Rev. Feb. 26, 2015) AC-3 American LegalNet, Inc. www.FormsWorkFlow.com