SELF-INSURER REQUEST TO ADD OR DELETE SUBSIDIARY/AFFILIATE Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency Self-Insured Programs PO Box 30016 Lansing, MI 48909 www.michigan.gov/wca Name of Current Self-Insurer 1. This is an Addition 2. Subsidiary/Affiliate Employer Records OFFICE USE ONLY Approved/Denied Effective ______________ _____________ Federal ID # Deletion Name Address Federal ID # City State Zip Code 3. Entity to be added was chartered under the laws of the state of ___________________________on______/________/_____. 4. Michigan locations (attach additional sheets if necessary) Name Address Federal ID # City State Zip Code 5. Effective date requested: _____/_____/_____ 6. Reason for addition/deletion ("acquisition," "out of business," "sold," etc.) FOR ADDITIONS ONLY: COMPLETE THIS SECTION R 408.43(3) of the Worker's Disability Compensation Act of 1969, as amended states: "Separate legal entities may be selfinsured under a single authority if they are majority-owned by the self-insured entity submitting the application or if the same person or group of persons owns a majority interest in each entity on a single application." 7. Does the existing self-insured employer have a majority ownership in the entity that will become self-insured? Yes No If Yes, % of ownership_________% 8. In the alternative, does the same person or group of persons own a majority interest in both the current self-insured and No If Yes, attach additional sheets that list the person or group of persons the entity to be added? Yes who own a majority interest in each entity and their % of ownership. NOTE: If questions 7 and 8 have both been answered: "No," the entity does not qualify for self-insured authority with the current self-insured. Yes No 9. Will a claims payment guaranty be furnished by parent or affiliate if required? 10. Total number of Michigan employees of entity to be added _______________ 11. Estimated amount of Michigan annual payroll for entity to be added $_________________ 12. If aggregate excess insurance is required for current program, estimate increase in retention $______________ NOTE: Please attach financial statements for the new employer if not consolidated in financial statements of the primary self-insured employer. AUTHORIZED SIGNATURE TITLE DATE LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-402A (8/11) Authority: Completion: Penalty: Worker's Disability Compensation Act of 1969, as amended Mandatory Denial/Termination of Self-Insured American LegalNet, Inc. www.FormsWorkFlow.com