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: