TEMPORARY AUTHORIZATION TO REVIEW INFORMATION
 

TO: The Ohio Bureau of Workers' Compensation

The Ohio Manufacturers' Association
33 North High Street
Columbus, OH 43215
1-800-662-4463
Fax (614) 224-1012
Policy Number: (Please leave out the "-000" portion of your Policy Number)
Company:   
DBA:   
Address:  
City:  
State:  
Zip:  
Note:  For this to be a VALID letter, the self-insured department for self-insured employers or the employer services department for all employers, must stamp it.  Being temporary in nature, BWC with 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 The Ohio Manufacturers' Association, 1788-80, 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:

  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 Application for Handicap Reimbursement (CHP-4);
  4. Notice of Appeal (IC-12) or Application for Permanent Partial Reconsideration (IC-88);
  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, 2009 or automatically nine months from date received by the employer services or self-insured departments, whichever is appropriate. In either case length of authorization will not exceed nine months.

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By typing my full name below and submitting this form I confirm the information provided is correct and I agree to follow all terms defined above.

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