Temporary Authorization to Review Information
To see if you are eligible for a group rating, complete the no obligation form on this page.
- Complete the items in the form below
- Click the SUBMIT button to review your entries before proceeding.
- This form is only applicable in Ohio.
If you would rather, download the PDF form here, fill it out and mail/fax it back to us at:
Employer Service Department; Ohio Bureau of Workers’ Compensation
c/o CareWorksComp Inc.
5500 Glendon Court
Dublin, OH 43016
This is to certify that CareWorksComp 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:
- Risk files
- Claim Files
- Merit-rated or non-merit rated experiences
- Other associated data
This authorization does NOT include the authority to:
- Review protest letters
- File protest letters
- File form CHP-4
- File Motions, I-12’s or IC-88’s
- File self-insurance applications
- Represent the employer at hearings
- Pursue other similar actions on behalf of the employer
- 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.