Self Insurers Claims Transfer Agreement Form. This is a Michigan form and can be use in Workers Comp.
Tags: Self Insurers Claims Transfer Agreement, Michigan Workers Comp,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. SELF-INSURER’S CLAIMS TRANSFER AGREEMENT : It is agreed between , Calendar No. , and : self-insured employer old service company , that all Plaintiff(s) workers' compensation filesJUDICIAL SUBPOENA previously serviced new service company -against- by : , on behalf of old service company for the self-insured employer self-insured period of : , through to , shall be transferred date date . : new service company Defendant(s) : Starting .with the date of transfer .of .the .claim files, . . . . . . . . . . . . . . . . . . ... .................. . .. ........ , will assume new service company all further responsibility for the proper handling of these files, including reporting to and advising the specific and aggregate excess insurance carrier(s), in accordance with the excess insurance contracts in force for the respective self-insured periods. In addition to the files being transferred, THE PEOPLE OF THE STATE OF NEW YORK , agrees to handle all future claims, pursuant to Rule 13m, reported new service company TO or re-opened for the self-insured period listed above. It is also agreed that all responsibility of , for the future handling old service company of claims incurred in the above-mentioned self-insured period, will terminate effective the date of transfer GREETINGS: of claims to . However, new service company , new service company WE COMMAND YOU, that by will not be responsible for any actions taken all business and excuses being laid aside, you while it was the attend before , and each of you old service company , at the Court . located at self-insured employer in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence asthis document have full authorityof the on behalf of their a witness in this action on the part to act It is also understood that representatives signing the Honorable servicing company of record for County of respective organizations and to enter into this agreement and fulfill its responsibilities and obligations provided, herein. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Self-Insured Employer New Service Company result of your failure to comply. By: By: Signature Witness, Honorable Court in County, Its: , one ofSignature the Justices of the day of , 20 Its: Title Title Date Signed: (Attorney must sign above and type name below) Date Signed: Old Service Company Attorney(s) for By: Signature Its: Title Office and P.O. Address Date Signed: Telephone No.: IF THE OLD SERVICE WISHES TO BE RELIEVED FROM FUTURE HANDLING OF CLAIMS TO CONCLUSION, THE OLD SERVICE Facsimile No.: COMPANY MUST REQUEST ARELEASE FROM THIS RESPONSIBILITY BY LETTER WITH A COPY OFTHIS AGREEMENTATTACHED. E-Mail Address: (Revised 01/97) Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. BUREAU OF WORKERS’ DISABILITY COMPENSATION R408.43m - EFFECTIVE MAY 11, 1999 : Calendar No. : R 408.43m Servicing self-insured employers or groups; application; requirements; noncompliance. JUDICIAL SUBPOENA Plaintiff(s) Rule 13m. (1) An individual, partnership, limited liability company, or corporation that desires to engage in the business of providing 1 or more services for an individual self-insurer or a self-insurers’ group shall apply to the bureau before entering into a -against: contract with the individual or group self-insurer and shall satisfy the bureau that it has adequate facilities and competent staff within the state to service a self-insured program in a manner that fulfills the employers’ obligations under the act and the rules of the bureau. : Service may include claims adjusting, loss control services, underwriting, and the capacity to provide required reporting. Any individual, partnership, limited liability company, or corporation that provides claims adjusting or loss control services to an approved self-insured : employer, where the self-insured employer has designated within its own organization an individual to be responsible to the bureau for its claims program or loss control services, or both, shall not be considered a service company for purposes of this rule. Defendant(s) (2) An applicant shall apply to the bureau for approval to act as a servicing company for self-insured employers or group funds : ...................................................... on a form prescribed by the bureau. The application shall contain answers to all questions. An applicant shall give the answers under oath. The bureau shall approve the application prior to the service company entering into a contract with an approved self-insurer. Approval to act as a service company for self-insurers is granted for a period of 1 year and is subject to renewal annually. (3) If a service company seeks approval to service claims for self-insurers, then it shall submit proof that it has, within its THE PEOPLE OF THE full-time OF NEW YORK organization or under contract on aSTATE basis, at least 1 person who has the knowledge and experience necessary to handle claims involving the act. The service company shall attach a resume covering the principal person’s background to the application of the service company. The principal individual adjusting workers’ compensation claims shall hold a current workers’ disability compensation TO adjuster’s license under chapter 12 of Act No. 218 of the Public Acts of 1956, as amended, being §500.1201 et seq. of the Michigan Compiled Laws. (4) If a service company seeks approval to provide underwriting service to self-insurers, then it shall submit proof that it has, within its organization or under contract on a full-time basis, at least 1 person who has the knowledge and experience necessary to provideGREETINGS: underwriting services for workers’ compensation excess liability insurance coverage. The service company shall attach a resume detailing the principal person’s background to the application of the service company. WE COMMAND YOU, that all business control services to laid aside, you and each of you attend before (5) If a service company seeks approval to furnish lossand excuses being self-insurers, then it shall submit proof that it has, within its organization or under contract on a full-time basis, at at the person who has the knowledge and background necessary to least 1 the Honorable Court adequately provide loss control and health services. at located County of (6) A service company shall maintain adequate staff in the state. The service company shall authorize staff to act for the service in room , on the day of , 20 , at o'clock in the noon, and at any recessed company on all matters covered by the act and the rules of the bureau. or adjournedcompany shall attach to theevidence asa copy of its standard servicethe part of the it will enter into with selfdate, to testify and give application a witness in this action on agreement that (7) A service insured employers or group funds. The service company shall certify, in writing, that the service agreement is in compliance with the act and these rules. The service company shall certify, and include a provision in its standard service contract which states, that the contract provides for the handling of all claims with dates of injury or disease within the contract until conclusion of the claims, unless Your relieved by the bureau, this subpoena responsibility for handling claim s. If the service contract liable to the service company is failure to comply with in writing, of theis punishable as a contempt of court and will make you calls for the party on whose behalf this subpoena was issued for a maximum penalty of $50 contract. For a service company additional fees for any reason, then the service company shall clearly define the additional fees in theand all damages sustained as a to be relievedof your failure to comply. result of the responsibility of handling claims to conclusion, the client, the previous service company, and the new service company shall sign a claims transfer agreement. The claims transfer agreement shall be completed on a form prescribed by the bureau and shall include a written request made by the previous service company to be relieved of its claims handling responsibilities to the Witness, Honorable , one of the Justices of the bureau. A requesting company is relieved of its claims handling responsibility only after receiving a written response from the bureau Court in County, day of , 20 approving a request. The service company shall certify that it will report to the specific excess insurance carrier or aggregate excess insurance carrier, or both, and put the specific excess insurance carrier or aggregate excess insurance carrier, or both, on notice of all claims as required by the self-insurers’ or group self-insurers’ insurance policies. The standard service contract filed with the bureau for approval and renewal of the service company authority shall include language specifically stating that the service company is (Attorney must sign above and type name below) responsible for reporting to the excess insurance carrier. The bureau may waive the reporting requirement upon written request to the bureau. Any dispute involving late reporting of excess liability insurance claims and potential penalties shall be reported to the bureau immediately. (8) A service company shall certify, and provide for in all service contracts, that all documents generated or prepared by the service company for the group or the individual self-insurer or any materials relatingAttorney(s) for or group self-insurer held by a service to an individual company are the property of the individual or group self-insurer and shall be surrendered to the individual or group self-insurer within 10 days of termination of the service contract, subject to written request by the individual or group self-insurer. (9) Failure to comply with the provisions of the act constitutes good cause for withdrawal of the approval to act as a service company for self-insurers. The bureau shall give 30 days’ notice of withdrawal. The bureau shall give the notice by certified or registered Office and P.O. Address mail, upon all interested parties. History: 1979 ACS 3, Eff. Sept. 3, 1980; 1984 MR 7, Eff. July 19, 1984; 1996 MR 3, Eff. Mar. 29, 1996; 1999 MR 4, Eff. May 11, 1999. 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