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.

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.