Insurers Notice Of Issuance Of Policy
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Insurers Notice Of Issuance Of Policy Form. This is a Michigan form and can be use in Workers Comp.
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Tags: Insurers Notice Of Issuance Of Policy, WC-400, Michigan Workers Comp,
INSURER’S NOTICE OF ISSUANCE OF POLICY
INSTRUCTIONS: SEE REVERSE SIDE
A separate Form 400 is required for
each legal entity insured under a policy
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Purpose of Form WC-400:
When Required:
General Guidelines for Completing Form WC-400:
should not
INSTRUCTIONS FOR COMPLETION
Item #1 – Employer Federal I.D. Number (9 digits)
required
Item #2 – Name of Business
same
Item #3 – Parent Co. Federal I.D. Number
Item #4 – Owner of Business (If applicable)
Item #5 – Mailing Address
Item #6 – Type of Organization
Item #7 – NAIC Carrier I.D. Number (9 digits)
Item #8 – ZIP Code of Issuing Office
Item #9 – Name of Insurance Company
Item #10 – Policy Number
Item #11 – Effective Date of Coverage
Item #12 – Annual Payroll in Dollars
Item #13 – Michigan Class Code
Item #14 – Number of Employees
Item #15 – Authorized Signature
Item #16 – Additional Names and/or Addresses of the Business
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