ORA WORKERS' COMPENSATION
Group Rating Plan Application 

To apply for group rating, please fill out and submit this online application: the AC-3. 

This form is only applicable in Ohio.


1. Complete the items in the application below.

2. Click the SUBMIT button for a quote.


QUESTIONS?

EMPLOYER SERVICES DEPARTMENT

Ohio Bureau of Workers’ Compensation

c/o Ohio Restaurant Association

100 E. Campus View Ste. 150

​Columbus, Ohio 43235


​P: 614.246.0205 | 866.331.6424

F: 614.442.9372

____________________________________________________________________________________________

This is to certify that CareWorks Comp (ID NO. 150-80) and OHIO RESTAURANT ASSOCIATION (13110, 2020/2021, Code 11/14) 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.


This 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 CHP-4

(4) File Motions, 1-12’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


I understand that this authorization is limited and temporary in nature and will expire on Jan. 31, 2020 or automatically six months from the date received by the Employer Services or Self-Insured Department, whichever is appropriate. In either case, length of authorization will not exceed six months.


(Typing name below constitutes electronic signature.)

To apply for group rating, please fill out and submit this online application: the AC-3. 

This form is only applicable in Ohio.


1. Complete the items in the application below.

2. Click the SUBMIT button for a quote.


QUESTIONS?

EMPLOYER SERVICES DEPARTMENT

Ohio Bureau of Workers’ Compensation

c/o Ohio Restaurant Association

100 E. Campus View Ste. 150

​Columbus, Ohio 43235


​P: 614.246.0205 | 866.331.6424

F: 614.442.9372

____________________________________________________________________________________________

This is to certify that CareWorks Comp (ID NO. 150-80) and OHIO RESTAURANT ASSOCIATION (13110, 2020/2021, Code 11/14) 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.


This 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 CHP-4

(4) File Motions, 1-12’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


I understand that this authorization is limited and temporary in nature and will expire on Jan. 31, 2020 or automatically six months from the date received by the Employer Services or Self-Insured Department, whichever is appropriate. In either case, length of authorization will not exceed six months.


(Typing name below constitutes electronic signature.)

Less