Michigan Department Of State Assigned Claims Facility 7064 Crowner Drive Lansing, MI 48918
For ACF Use Only Date of Application: Effective Date: Certificate #: Expiration Date:
APPLICATION FOR SELF-INSURANCE CERTIFICATE
Name of Applicant: Address: City, State, Zip: (Name and Address as it is to appear on Certificate) Telephone No.: E-Mail Address: Fax No.:
List the names and addresses of the three principal officers of the company: 1. Name: Title: Address: City, State, Zip: Telephone No.: E-Mail Address: Name: Title: Address: City, State, Zip: Telephone No.: E-Mail Address: Name: Title: Address: City, State, Zip Telephone No.: E-Mail Address:
Name and address of representative authorized to receive and process claims: Name: Title: Address: City, State, Zip: Telephone No.: E-Mail Address:
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Name and address of person authorized to accept the invoice for Assigned Claims Facility Annual Assessment: Name: Title: Address: City, State, Zip: Telephone No.: E-Mail Address:
(A) The number of motor vehicles, excluding trailers, motorcycles, and mopeds registered in Michigan in the applicant's name as of the date of this application: A= (B) The number of motor vehicles, not included in (A) including trailers with more than 2 wheels, but excluding motorcycles and mopeds owned by or registered to the Applicant, that are to be self-insured under this application, including motor vehicles or trailers having more than 2 wheels, rented or leased by the Applicant for more than 30 days. All motor vehicles, including trailers having more than 2 wheels must be accounted for in (A) or (B), in order to be self-insured under a Certificate of Self-Insurance issued for this application: B= Total = Total Number of Vehicles (A + B): Fill in Net Worth and Loss Reserve and cite reference (page number) as applicable to your Statement of Financial Status. Net Worth: $ As documented in our audited Statement of Financial Status on page #
As documented in our audited Statement of Financial Status on page #
Name and address of financial institution in which Loss Reserve is maintained: Name: Address: Address: City, State, Zip: The Applicant hereby applies for the privilege of being a self-insurer under the No-Fault Insurance Act and the 2 Michigan Vehicle Code. In consideration of the privilege of being certified as a self-insurer for the purposes of the No-Fault Insurance Act and the Michigan Vehicle Code, the Applicant hereby agrees to the following: (a) To comply with all the provisions of the Michigan No-Fault Insurance Act, 3 the Financial Responsibility Act, and the Administrative Rules for no-fault self4 insurers. (b) To notify the Secretary of State, State of Michigan, promptly of any change in the Applicant's financial condition that may affect its ability to maintain the required loss reserve or of a reduction of the Applicant's net worth below that 5 required by Rule 2 of the No-Fault Self-Insurance Rules for the issuance of a Certificate of No-Fault Self-Insurance.
NF-37 (12/02) Page 2 of 2
The Applicant hereby certifies that the statements set forth in this application are true and correct.
Authorized Officer (Print Name)
Title of Authorized Officer
__________________________________________ Signature of Authorized Officer
Subscribed and sworn to before me this _______ day of ______________________, 20______.
__________________________________________ Notary Public
Chapter 31 of 1956 PA 218, as amended; MCL 500.3101 et seq. 1949 PA 300, as amended; MCL 257.1 et seq. 3 Chapter V of the Michigan Vehicle Code; MCL 257.501 to 257.532 4 2000 AC R 257.531 to R 257.540 5 2000 AC R 257.532
Send completed application package to: Assigned Claims Facility 7064 Crowner Drive Lansing, MI 48918
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