OCR 400 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 American LegalNet, Inc. www.FormsWorkFlow.com 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 American LegalNet, Inc. www.FormsWorkFlow.com