Please fill out the form fields below or email firstname.lastname@example.org and a member of our team will get back to you.
NOTE: For this to be a VALID letter, the employer services department for all 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 V&A Risk Services 217143-80 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:
This authorization does NOT include the authority to:
I understand that this authorization is limited and temporary in nature and will expire on 1/31/2018 or automatically nine months from the date received by the Employer Services Department or Self-Insured Department, whichever is appropriate. In either case, the length of authorization will not exceed nine months.
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.
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.