Group Rating Application

Temporary Authorization to Review Information

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Electronic Application Form

Please note that fields in RED are required. This form is only applicable in Ohio.

TO: Employer Service Department; Ohio Bureau of Workers' Compensation

c/o Compensation Consultants Inc.
5500 Glendon Court
Suite 300 P.O. Box 8101
Dublin, OH 43016
Fax: 614-764-7629
Toll Free: 800-837-3200
info@cciworkerscomp.com

Temporary Authorization
To Review Information

Policy Number
Association/Chamber Name
Company
DBA
Address
City
State
Zip

This is to certify that Compensation Consultants 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.

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.

Signature: (typing name below constitutes electronic signature)	Title:	Date:

Print Name:	Telephone:	Fax:

	Email:


If you would rather, download the PDF application here , fill it out and mail it back to us.