ORA Workers' Compensation Group Rating Plan - AC-3

To apply for group rating, use our automatic form generator. This form is only applicable in Ohio.

1. Complete the items in the form below

2. Click the SUBMIT button for a quote

TO: EMPLOYER SERVICES DEPARTMENT

Ohio Bureau of Workers’ Compensation
c/o Ohio Restaurant Association
1525 Bethel Road, Suite 301
Columbus, OH 43220

​(614) 246-0205 / (866) 331-6424
FAX (614) 442-9372

This is to certify that CareWorksComp (ID NO. 150-80) and OHIO RESTAURANT ASSOCIATION (13110, 2018/2019, 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, 2018 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)

This is to certify that CareWorksComp (ID NO. 150-80) and OHIO RESTAURANT ASSOCIATION (13110, 2018/2019, 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, 2018 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)