Temporary Authorization to Review Information

To apply for group rating online, use the form at the bottom of this page.

  1. Complete the items in the form below
  2. Click the SUBMIT button to review your entries before proceeding.
  3. This form is only applicable in Ohio.

Apply

Policy Number:
Association/Chamber Name:
Company:
Email:
DBA:
Address:
City:
Zip Code:
Electronic Signature:
Entering your name in the adjacent textbox constitutes an electronic signature.
Title:
Date:
Telephone:
Fax:

If you would rather, download the PDF application here, fill it out and mail/fax it back to us at:

Employer Service Department; Ohio Bureau of Workers’ Compensation
c/o CareWorks Consultants Inc.
5500 Glendon Court
Dublin, OH 43016

OR

Fax: 888.837.3288

This is to certify that CareWorks 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
  8. 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.