“I saved a bundle with COSE’s Workers’ Comp plan, and you can too. Request a quote today.”

Join Jeb and the hundreds of small businesses who are enjoying outstanding premium discounts and COSE’s unparalleled level of service. Take a few minutes to fill out the AC-3 form to the right. We will contact you shortly to verify that your submission has been received. You can also click HERE to download a printable PDF version of the AC-3 form. For more information on the COSE Workers’ Comp program, visit cose.org/workerscomp or call 216-592-2351.

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*Required

I understand that this authorization is limited and temporary in nature and will expire on February 28, 2011 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 above constitutes electronic signature.

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:

  1. Risk files
  2. Claims files
  3. Merit-rated or non-merit rated experiences
  4. Other associated data
The authorization does NOT include authority to:

  1. Review protest letters
  2. File protest letters
  3. File form CHP-4
  4. File Motions, 1-12’s or IC-88’s
  5. File self-insurance applications
  6. Represent the employer at hearings
  7. Pursue other similar actions on behalf of the employer