AC-2 Authorization for PPS

This authorization supersedes all permanent authorizations on file for the ERC designation.

Understand and agree BWC will process any letters, requests and actions initiated by a superseded authority. This authorization, now being granted, is of a continuous nature from the effective date upon submission.

However, the employer possess the right to terminate this authorization at any time through written notification to the employer services or self-insured departments as appropriate.

Policy Number
Company
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Electronic Signature
Title
Phone
Fax
Email

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