Ohio AC3 Form

Cost Savings Eligibility

Fill out this no obligation form to see if you are eligible for a group rating.

  • Date Format: MM slash DD slash YYYY
Mail or Fax

If you would rather, you can download the PDF form here, fill it out and mail/fax it back to us at:

Employer Service Department; Ohio Bureau of Workers’ Compensation
c/o CareWorks Comp Inc.
5500 Glendon Court
Dublin, OH 43016

Fax: 1.888.837.3288

This is to certify that CareWorks Comp Inc. (ID No.150-80)(Code 31/00) including its agents or representatives identified to you by them, has been retained to review and perform studies on certain workers’ compensation matters on your behalf.

Limited letter of authority and authorization

The limited letter of authority provides access to the following types of information relating to your 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 CHP-4
  4. File Motions, I-12’s or IC-88’s
  5. File self-insurance applications
  6. Represent the employer at hearings
  7. Pursue other similar actions on behalf of the employer

I understand that this authorization is limited and temporary in nature and will expire on February 28 or automatically nine months from date received by the Employer Services or Self-Insured Section, whichever is appropriate. In either case length of authorization will not exceed nine months.