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OhioBWC - Employer:  (Instructions for completion of the Permanent Authorization (AC-2))

Instructions for the completion of the Permanent Authorization

For the employer to authorize a third party to represent it before BWC or the Industrial Commission of Ohio, the following form is required to name a third party representative.

  1. Check boxes: Please check “Self-Insured Section.”
  2. From: Policy Number: Please enter your BWC policy number.
  3. Entity: Enter your company’s name as it appears on the articles of incorporation.
  4. DBA (doing business as): Enter your company’s DBA, if any.
  5. Address: Please list your company’s address including street, P. O. Box, city, state and nine digit zip code.
  6. Date (line): Enter the date that the agreement is to take effect.
  7. Representative’s name and address: On this line enter the company name of the authorized representative along with their street, P. O. Box, city state and nine digit zip code.
  8. Signature: A person authorized to sign for your company should sign the form.
  9. Title: Enter the title of the person signing the form.
  10. Date: Enter the date that the form was signed.
Print Agreement of Permanent Authorization Form (AC-2)