risk management. we know the territory.

AC3 Temporary Authorization Form

Completion of the temporary authorization provides us limited authority to view payroll and loss experience. By completing the AC-3, the employer grants permission to the BWC to release information to The Matrix Companies

Paycor Client*: YesNo

I certify that the information is true to the best of my knowledge.*

You may also download the pdf and mail or fax the completed form to:

The Matrix Companies
644 Linn St.
Suite 900
Cincinnati, Ohio 45203

Fax: 513.366.3362

AC3 Temporary Authorization Form Button