Request to Add/Change or Terminate Permanent Authorization (AC-2)

This form allows an employer or employer representative to authorize access to a company's policy and/or claim(s), change authorization access or terminate access based on the type of representation requested.
Note: There must be a hard copy of the AC-2 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
  • Authorized representative ID/Name
  • Authorized representative type
  • Name of person who completed hard copy AC-2
  • Title of person who completed hard copy AC-2
  • Actual date of completed hard copy AC-2

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