Free SELF-INSURER REQUEST - Michigan

SELF-INSURER REQUEST TO ADD OR DELETE SUBSIDIARY/AFFILIATE
Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency Self-Insured Programs 7150 Harris Drive (48913) PO Box 30016 Lansing, MI 48909 www.michigan.gov/wca Name of Current Self-Insurer 1. This is an Addition 2. Subsidiary/Affiliate Deletion
Name Address

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Employer Records

OFFICE USE ONLY Approved/Denied Effective ______________

_____________

Federal ID #

Federal ID #
City State Zip Code

3. Entity to be added was chartered under the laws of the state of___________________________on______/________/_____. 4. Michigan Locations (attach additional sheets if necessary)
Name Address

Federal ID #
City State Zip Code

5. Effective date requested: _____/_____/_____ 6. Reason for addition/deletion ("acquisition", "out of business", "sold", etc.)

FOR ADDITIONS ONLY: COMPLETE THIS SECTION
R 408.43(3) of the Worker's Disability Compensation Act of 1969, as amended states: "Separate legal entities may be selfinsured under a single authority if they are majority-owned by the self-insured entity submitting the application or if the same person or group of persons owns a majority interest in each entity on a single application." 7. Does the existing self-insured employer have a majority ownership in the entity that will become self-insured? Yes No If Yes, % of ownership_________% 8. In the alternative, does the same person or group of persons own a majority interest in both the current self-insured and Yes No If Yes, attached additional sheets that list the person or group of persons the entity to be added? who own a majority interest in each entity and their % of ownership. NOTE: If questions 7 and 8 have both been answered: "No", the entity does not qualify for self-insured authority with the current self-insured. 9. Will a claims payment guaranty be furnished by parent or affiliate if required? Yes No 10. Total number of Michigan employees of entity to be added _______________ 11. Estimated amount of Michigan annual payroll for entity to be added $_________________ 12. If aggregate excess insurance is required for current program, estimate increase in retention $______________ NOTE: Please attach financial statements for the new employer if not consolidated in financial statements of the primary self-insured employer.
AUTHORIZED SIGNATURE TITLE DATE

Authority: Completion: Penalty:

Worker's Disability Compensation Act of 1969, as amended Mandatory Denial/Termination of Self-Insured Status

The Department of Energy, Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this Agency.

WC-402A (01/09)