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