AC3Info

Temporary Authorization to Review Information AC-3 form

To receive a no cost or obligation group rating review, please complete the items below. When you are finished, click "SUBMIT AC-3 form". If you prefer, you can print the form and fax it toll-free to our office at 866-567-9380.

CompManagement, Inc., a Sedgwick CMS Company, will then obtain your workers' compensation experience from the Ohio Bureau of Workers' Compensation to determine your company's eligibility for our group rating program. In the Fall, we will mail you the results of our group rating review for your consideration.
Note: Items in RED are required.

Policy No.
Company Name
Doing Business As
Address
City,State & Zip	,
Phone No.	xxx-xxx-xxxx Extension
Fax No.	xxx-xxx-xxxx

Sponsoring Chamber:

I certify that the information is true to the best of my knowledge.

Authorized by:
Title:
Email Address:
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