To check your eligibility for our group, group retro and other programs, please enter and submit the following information:
Entering your name in the First and Last Name fields constitutes your electronic signature.
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, Hunter Consulting Company 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.
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.
Note: 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.
On submitting this form, you understand this authorization is limited and temporary in
nature and will expireautomatically 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.
Please Select your Chamber:
Joint Vocational School District
Career Technical Planning District
Adams County Chamber of Commerce
African American Chamber of Commerce
Anderson Area Chamber of Commerce
Beavercreek Chamber of Commerce
Bellbrook-Sugarcreek Area Chamber
Blanchester Chamber of Commerce
Brookville Chamber of Commerce
Brown County Chamber
Celina-Mercer County Chamber of Commerce
Chamber of Commerce of Yellow Springs
Chamber of Commerce Serving Middletown, Trenton and Monroe
Chamber of Southwestern Auglaize Co.
Colerain Chamber of Commerce
Darke Co Chamber of Commerce
Eaton-Preble County Chamber of Commerce
Englewood Northmont Chamber of Commerce
Evendale Chamber of Commerce
Fairfield Ohio Chamber of Commerce
Forest Park Chamber
Franklin Area Chamber of Commerce
Greater Hamilton Chamber of Commerce
Greater Springfield Chamber of Commerce
Highland Cty. Chamber of Commerce
Huber Heights Chamber of Commerce
Independent Electrical Contractors Associations
Jamestown Chamber of Commerce
Kettering Moraine Oakwood Area COC
Little Miami Chamber
Loveland Chamber of Commerce
Madiera Chamber of Commerce
Madison County Chamber
Mason Area Chamber of Commerce
Montgomery Chamber of Commerce
Norwood Chamber of Commerce
Ohio Craft Brewers Association
Ohio Roofing Contractors Association
Reading Chamber of Commerce
Riverside Area Chamber of Commerce
Sharonville Chamber of Commerce
Sidney Chamber of Commerce
South Metro Dayton Area Chamber
Southern Ohio Chamber Alliance
Southwestern Ohio Educational Purchasing Council
Spring Valley Chamber of Commerce
Springboro Chamber of Commerce
St Marys Chamber of Commerce
Tipp City Chamber of Commerce
Tri-County Restaurant Association
Troy Area Chamber of Commerce
Union County Chamber
Urbana-champaign County Chamber of Commerce
Vandalia Butler Chamber of Commerce
Waynesville Area Chamber of Commerce
West Chester - Liberty Chamber Alliance
Whitehall Area Chamber
Wilmington Clinton Cnty Chamber of Commerce
Woodlawn Chamber of Commerce
Xenia Area Chamber of Commerce