Request a Quote

AC3 - Temporary Authorization to Review Information

Complete the following to determine your eligibility for group rating, Group Retrospective Rating and other discount programs. 

Compensation Solutions Inc. provides this service with no charge or obligation.

If you wish to mail or fax an AC-3 Form please remit to the following address or by fax:

Compensation Solutions, Inc.
ATTN: Group Rating
470 Village Park Drive
Powell, Ohio 43065
Phone: (888) 776-7723
Fax: (888) 776-7741


 

*Policy #
*Company Name
*Contact Name

 

*Entering your name below constitutes an electronic signature.

*Electronic Signiture
Title
*Phone
Fax
*Email
How did you hear about us?

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move