Request Temporary Authorization (AC-3)
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.
- Policy number OR Federal tax ID/SSN
- Entity name & DBA
- 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.