From: Policy Number

Company Name:
Doing Business As:
Address:
 
 

This is to certify that CompManagement, Inc., Rep. ID #000900-80

including its agents or representatives identified to you by them, has been retained to review and perform studies on certain workers’ compensation matters on our behalf.

The limited letter of authority provides access to the following types of information relating to our account:

  1. Risk files

  2. Claim files

  3. Merit-rated or non-merit rated experiences

  4. Other associated data

This authorization does NOT include the authority to:

  1. Review protest letters
  2. File protest letters
  3. File form CHP-4
  4. File Motions, I-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

I understand that this authorization is limited and temporary in nature and will expire on 12/31/00 or automatically six months from date received by the Risk Technical Department or Self-Insured Section, whichever is appropriate. In either case length of authorization will not exceed six months.

Signature

 

 

 Title Date

Print Name

 

 

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