APPLICATION FOR AUTHORIZATION BY SELF-INSURED EMPLOYER OR GROUP FUND FOR SERVICING AGENT DEG USER ACCOUNT Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 A new application must be submitted whenever there is a change in service company. Date of Application 1. SELF-INSURED OR GROUP FUND INFORMATION 1. Self-Insured Number or FEIN 3. Address (Street number and name) 7. Telephone Number (Include area code) 2. Name 4. City 5. State 6. ZIP Code 8. Contact Person 9. Email 2. SERVICE COMPANY INFORMATION 10. Agency Assigned Number 12. Address (Street number and name) 11. Name 13. City 14. State 15. ZIP Code 16. Telephone Number (Include area code) 17. Contact Person 18. Email By signing this form, I certify that the information included on this form is correct and complete to the best of my knowledge and that the servicing agent shown above has the authority to act as our agent and submit forms through the DEG as required by law. I understand that submitting false information is cause for denial of the application. 19. Self-Insured or Group Fund Authorized Signature 20. Name (Printed) 21. Email 22. Date LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. . WC-450 (5/14) American LegalNet, Inc. www.FormsWorkFlow.com