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Pdf AC 3 Form

Edition Date:6/27/2005

Information:Authorization for AultComp Administrators including its agents or representatives to review and perform studies on certain workers’ compensation matters on our behalf.

For this to be a VALID letter,It must be stamped by the Self-Insured Department for self-insured employers or by the Employer Services Department for all employers other than self-insured. This authorization,being temporary in nature,will not be recorder via computer or be retained by the Employer Services Department. A copy must be in the possession of a representative when requesting service relative to the authoriy granted therein.

This information should be mailed to:
AultComp Administrators
PO BOX 6404
Canton, OH 44710

Phone: 330-363-5084
Fax: 330-580-6653
Email: aultcomptpa@aultman.com