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.