May 24, 2024

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In order to receive a group rating quote for the July 2023 through June 2024 Ohio Workers' Compensation premium year, an AC-3 and company profile form must be completed and submitted to

By submitting the AC-3 form, you are giving Minute Men HR Risk temporary authorization to receive the necessary claims history information from the Ohio Bureau of Workers' Compensation, which is used to determine group eligibility status and the premium discount your company may be entitled to.

If you are seeking a quote for more than one company, an AC-3 form must be completed for each individual OBWC policy number.

Should you need any assistance in submitting the AC-3 and company profile form or have any questions, you may contact Mike Cipullo at 216-452-0100 x145.

Please note that submission of the AC-3 does not guarantee group enrollment and/or premium discount.

There are two ways to fill out the required forms. You may download the printable PDF form, fill it out, and fax it back to us at 216-426-2254. Or you may fill out the online form for faster processing.

Please choose an option below:

   • Easy to fill out
 • Confirmation by email
 • Faster processing