Temporary Authorization To Review Information - Ohio Bureau Of Worker'S Compensation

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Temporary Authorization
to Review Information
From: Policy number
To:
Ohio Bureau of Workers' Compensation
Entity
Employer Services Department, 22nd Floor
Self-Insured Department, 22nd Floor
DBA
Please mark a box and return to:
Address
30 W. Spring St.
Columbus, Ohio 43215-2256
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
This authorization does not include the authority to:
types of information relating to our account:
1.
Review protest letters;
1.
Risk files;
2.
File protest letters;
2.
Claim files;
3.
File form Application for Handicap Reimbursement (CHP-4);
3.
Merit-rated or non-merit-rated experiences;
4.
Notice of Appeal (IC-12) or Application for Permanent
4.
Other associated data.
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

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