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. will then obtain your workers' compensation experience from the Ohio Bureau of Workers' Compensation to determine your company's eligibility for the group rating program. In the Fall, we will mail you the results of the 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 

Association, Chamber, or Agent Name:

 

 
 
Authorized by:   
Title:   
Email Address:     
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