Fill out and submit this AC-3 form and it will automatically be sent to our Group Rating Client Services Department. We will contact you shortly to verify that your AC-3 submission has been received.

AC-3 Form

* Association Sponsors:
* Policy Number:
* Business Name:
* Address:
* City:
* State:
* Zip: -
Typing name below constitutes electronic signature
* First Name:
* Last Name:
* Telephone: - -
Fax: - -

*Required fields.

You may also download a printable AC-3 form from our Association Sponsors Page, which can be filled out by hand and sent to the attention of our Client Services Department at:

Frank Gates
P.O. Box 182364
Columbus, OH 43218-2364
Fax: 614-798-5510

Contact us with questions at 800-395-4119.


Click here to learn more about Frank Gates group rating programs.