Today’s Date Temporary Authorization to Review Information – AC-3 To check your eligibility for our group, group retro and other programs, please enter and submit the information below. Policy Number Company DBA Street City State Zip Code Ohio County Employer TypePlease select… Private Public Entering your name in the First and Last Name fields constitutes your electronic signature. First Name Last Name Title Telephone Number Fax Number Email 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 Sheakley Uniservice, Inc 370-80, 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-related or non-merit related 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 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. 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. I understand this authorization is limited and temporary in nature and will expire 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. I Agree Date Need assistance with this form?