July 18, 2019

AC-3 Form

Temporary Authorization to Review Information AC-3 Form
To receive an independent review of your Ohio Workers' Compensation coverage, please complete the items below. When you are finished, click "SUBMIT" . If you prefer, you can print the form and fax it to our office at 614-763-0802. RHK Group will then obtain your information through our actuary vendor from the Ohio Bureau of Workers' Compensation (BWC). We will review your data and prepare cost saving recommendations for your consideration.
AC-3 Form
Policy Number *
Company Name *
Doing Business As
Address
City
State
Zip
Business Phone
Fax
Authorization
Authorized By
Title
E-mail Address
* = Required Field