The two page form MUST BE PRINTED and returned via U.S. Mail to KKSG & Associates, 67 East Wilson Bridge Road, Suite 201, Worthington, Ohio 43085 due to the fact it is a legal Temporary Authorization To Review Information at the Ohio Bureau of Workers' Compensation.



7 - 1 - 98                        Temporary Authorization
To Review Information

From: Risk # _________________________
Entity _______________________________
D.B.A. _______________________________
Address _____________________________
_____________________________

Note:    To be valid this letter must be stamped by the Self-Insured
Section for Self-Insured Employers or by the Actuarial Section for all
Employers other than Self-Insured.  This Authorization, being
temporary in nature, will not be recorded via CRT.  A copy must
be in possession of representative when requesting services relative
to the authority grated herein.

This is to certify that KKSG & Associates, Inc.  #001648-80
including its agents or representatives identified to you by them, has been temporarily retained to review and perform studies on certain Workers' Compensation matters on our behalf.

This 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, 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

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



_____________________        _____________________       _______________
(Signature)                                        (Title)                                              (Date)

Distribution:
        1 Copy-Actuarial Section for all Risks other than Self-Insured
        1 Copy-Temporary Representation
        1 Copy-Risk

BWC-0503 (Rev. 5/83)
AC-3

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