Ohio ERIC

Department of Job and Family Services

Employer Resource Information Center

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* Required Field

* Legal Entity Name:

Trade Name (Doing Business As):

Third Party Administrator Type:

International Address?:

Yes

No

Attention:

* Address Line 1:

Address Line 2:

* City:

* State:

Province:

* Country:

* Zip: -

* Postal Code:

* Email Address:

* Email Address Confirmation:

Email Address:

Email Address Confirmation:

* Phone Number 1: - Ext:

Phone Number 2: - Ext:

Phone Number 3: - Ext:

Fax Number: -

Delivery Method:

Postal Mail

Email