By filling out and submitting this AC-3 form electronically, it will automatically be directed COSE Compensation Services. We will contact you shortly to verify that your AC-3 submission has been received.

Click HERE to download a printable PDF version of the AC-3 or fill out the electronic version below:

I understand that this authorization is limited and temporary in nature and will expire on February 28, 2009 or automatically nine months from date received by the Employer Services or Self-Insured Section, whichever is appropriate. In either case length of authorization will not exceed nine months. Typing your name below constitutes electronic signature.

Policy Number (8 digits):
COSE Member ID:		First Name:
Business Name:		Last Name:
DBA:		Title:
Address:		Telephone (10 digits, no dashes or spaces):
City:		Fax (10 digits, no dashes or spaces):
State:	Ohio Alberta British Columbia Inuit Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Province de Québèc Saskatchewan Yukon Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	E-mail:
Zip:		=Required
This is to certify that COSE Compensation Services. (ID No.218265-80) including its agents or representatives identified to you by them, has been retained to review and perform studies on certain workers' compensation matters on your behalf. The limited letter of authority provides access to the following types of information relating to your account: Risk files Claim Files Merit-rated or non-merit rated experiences Other associated data This authorization does NOT include the authority to: Review protest letters File protest letters File form CHP-4 File Motions, I-12's or IC-88's File self-insurance applications Represent the employer at hearings Pursue other similar actions on behalf of the employer