WORKERS DISABILITY COMPENSATION GROUP SELF-INSURER APPLICATION Michigan Department of Licensing and Regulatory Affairs Workers Compensation Agency Self-Insured Programs 7150 Harris Drive (48913) PO Box 30016 Lansing, Michigan 48909 LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. 1. Authority: Completion: Penalty: New Renewal Workers Disability Compensation Act of 1969, as amended Mandatory Denial/Termination of Self-Insured Status APPLICANT: Applicant Group: Address: City, State, Zip Code: 2. TRUSTEES: Name: 3. FEIN No. Business Address: ADMINISTRATOR: Name: Telephone: Address: Fax Number: 4. CLAIMS PROGRAM: Service Company: Telephone: Address: Fax Number: 5. SAFETY PROGRAM: Name: Telephone: Address: Fax Number: 6. ON NEW APPLICATIONS: Attach an exhibit detailing the following by applicable code classification for the proposed year: code classification, payroll, rate per $100, manual premium, modified premium and discount, if applicable. 7. ON RENEWAL APPLICATIONS: Attach an exhibit detailing the following by applicable code classification for the renewal year: code classification, payroll, rate per $100, manual premium, modified premium and discount, if applicable. Number of Employer Members: (Attach Membership List) Group Experience Modifier: Excess Carrier: Standard Premium: Policy Number: Discounts: Total Estimated Premium: Collectable Premium: RENEWAL APPLICANTS MUST ATTACH A CURRENT LOSS SUMMARY FOR ALL GROUP YEARS, AND A COPY OF THE CURRENT FINANCIAL REPORT. WC-402GR (Rev. 9/11) American LegalNet, Inc. www.FormsWorkFlow.com 8. EXCESS INSURANCE AND BOND INFORMATION: Specific Excess Policy Limit: Aggregate Excess Policy Limit: Retention: Term: Term: Loss Fund % of Collectable Premium: Fidelity Policy: Amount: Estimated Loss Fund: Bond Number: Carrier: Surety Bond: Amount: Minimum Loss Fund: Bond Number: Carrier: ALL EXCESS INSURANCE TERMS MUST BE CONFIRMED AND PROVIDED WITH THE APPLICATION, INCLUDING A COPY OF THE GROUPS FIDELITY POLICY WITH PROOF THAT THE FIDELITY POLICY IS CURRENT. THIS APPLICATION MUST BE RECEIVED BY THE AGENCY 30 DAYS PRIOR TO ITS EFFECTIVE DATE. 9. PROJECTED ADMINISTRATIVE EXPENSE: Estimated Collected Premium: ______________________ In dollars As % of premium Excess Insurance: Service Company Fee: Bonds and Other Insurance: General Administrative Expenses: ATTACH A COPY OF THE SERVICE COMPANY AND ADMINISTRATOR CONTRACTS. In consideration of the privilege of being a group self-insurer, we hereby agree: a. That we will discharge our liability for compensation to injured employees or their dependents in accordance with the requirements of the Michigan Workers Disability Compensation Act of 1969, as amended. b. That we will follow the administrative rules of the agency and any additional conditions imposed by the agency as part of our approval. c. That we will promptly furnish all reports to the Workers Compensation Agency which it may lawfully require under the Michigan Workers Disability Compensation Act of 1969, as amended. d. That we will notify the Workers Compensation Agency promptly of any unfavorable turn in our financial condition which might reasonably reduce our ability to carry our own risk under the Michigan Workers Disability Compensation Act of 1969, as amended. We affirm all information submitted as being true. GROUP NAME: NOTARY SIGNATURE: COUNTY OF: BY: Type Name of Person Signing TITLE: Title of Person Signing SIGNATURE: WC-402GR (Rev. 9/11) MY COMMISSION EXPIRES: DATE: AFFIX STAMP: American LegalNet, Inc. www.FormsWorkFlow.com