June 8, 2023
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ONLINE AUTHORIZATION FORM
Please note that fields in
RED
are required. This form is only applicable in Ohio.
TO: The Ohio Bureau of Workers' Compensation Risk Technical Services Department (L-22)
Minute Men HR
3740 Carnegie Avenue
Cleveland, OH 44115
Fax: 216-426-2254
Toll Free: 877-873-8856
TEMPORARY AUTHORIZATION
TO REVIEW INFORMATION
From (Policy Number):
Entity:
DBA:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
This is to certify that
Minute Men HR REP #001633-80
including its agents or representatives identified to you by them, has been retained to review and perform studies on certain workers' compensation matters on 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
I understand that this authorization is limited and temporary in nature and will expire on
or automatically nine months from date received by the Risk Technical Department or Self-Insured Section, whichever is appropriate. In either case length of authorization will not exceed nine months.
Signature:
Title:
Date:
(typing name below
constitutes electronic signature)
Print Name:
Telephone:
Fax:
COMPANY PROFILE
Group Rating Contact:
E-Mail Address:
Who is your current
Managed Care Organization (MCO)?
Who is your current
Third Party Administrator?
Has your company been a PEO client in the last 5 years?
Yes
No
If your company is determined to be non-group eligible, would you be
interested in a quote for workers' compensation management services?
Yes
No
How did you hear about OhioGroupRating.com?
--Select--
Postcard
Radio ad
Search engine
E-mail newsletter
From another web site
Someone told me about it
----------------
American Welding Society
Heartland Payroll Company
Ohio Grantmakers Forum
----------------
(other)
OhioGroupRating.com
3740 Carnegie Avenue
Cleveland, Ohio 44115
Web Design: Pavlish Group
Toll Free: 877.873.8856
Part of the
Minute Men Human Resource System