Temporary Authorization to Review Information AC-3 Form

To receive a no cost or obligation group rating or other alternative rating programs review, please complete the items below. When you are finished, click "SUBMIT AC-3 form". If you prefer, you can print the form and fax it toll-free to our office at (866) 567-9380.

Sedgwick will then obtain your workers' compensation experience from the Ohio Bureau of Workers' Compensation (BWC) to determine your company's eligibility for a group program or other alternative rating programs. We will mail you the results of our review for your consideration at the appropriate marketing period as determined by BWC.
Note: Items in RED are required.

Policy No.   
Company Name   
Doing Business As
City, State & Zip ,  
Phone No.  xxx-xxx-xxxx  Extension
Fax No.  xxx-xxx-xxxx 

Association, Chamber, or Agent Name:


Authorized by:   
Email Address: