Introduction

This form allows an employer to grant temporary authorization to a third-party administrator to review information. Note: There must be a hard copy of the AC-3 on site at the employer's before you can submit the form here online. This authorization will supersede all current authorizations on file for the representative type chosen.

Required information

• Policy number OR Federal tax ID/SSN
• Entity name & DBA
• Address
• Authorized representative ID/Name
• Expiration date
• Name of person who completed hard copy AC-3
• Title of person who completed hard copy AC-3
• E-mail and phone number
• Signature of person authorizing
• Actual date of completed hard copy AC-3

If you have all the required information on hand, simply click the start button to begin.