WORKERS DISABILITY COMPENSATION GROUP SELF-INSURER APPLICATION Michigan Department of Licensing and Regulatory Affairs Workers Compensation Agency Self-Insured Programs PO Box 30016 Lansing, Michigan 48909 New Renewal LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Authority: Completion: Penalty: Workers Disability Compensation Act of 1969, as amended Mandatory Denial/Termination of Self-Insured Status 1. APPLICANT: Applicant Group: Address: City, State, Zip Code: FEIN No. 2. TRUSTEES: Business Address: Name: 3. ADMINISTRATOR: Telephone: Fax Number: Name: Address: 4. CLAIMS PROGRAM: Telephone: Fax Number: Service Company: Address: 5. SAFETY PROGRAM: Telephone: Fax Number: Name: Address: 6. 7. 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. 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. Group Experience Modifier: Standard Premium: Discounts: Collectable Premium: Number of Employer Members: (Attach Membership List) Excess Carrier: Policy Number: Total Estimated Premium: RENEWAL APPLICANTS MUST ATTACH A CURRENT LOSS SUMMARY FOR ALL GROUP YEARS, AND A COPY OF THE CURRENT FINANCIAL REPORT. Print WC-402GR (Rev. 9/11) Save Document Reset All Pages American LegalNet, Inc. www.FormsWorkFlow.com 8. EXCESS INSURANCE AND BOND INFORMATION: Aggregate Excess Policy Limit: Term: Loss Fund % of Collectable Premium: Amount: Bond Number: Carrier: Specific Excess Policy Limit: Retention: Term: Fidelity Policy: Estimated Loss Fund: Surety Bond: Amount: Bond Number: Carrier: Minimum Loss Fund: 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. b. c. d. 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. That we will follow the administrative rules of the agency and any additional conditions imposed by the agency as part of our approval. 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. 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 MY COMMISSION EXPIRES: DATE: AFFIX STAMP: TITLE: Title of Person Signing SIGNATURE: Print WC-402GR (Rev. 9/11) Save Document Reset All Pages American LegalNet, Inc. www.FormsWorkFlow.com