WORKERS' COMPENSATION AGENCY SERVICE COMPANY APPLICATION Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency Self-Insured Programs PO Box 30016 Lansing, MI 48909 LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Name of Applicant Authority: Workers' Disability Compensation Act of 1969, as amended Completion: Mandatory Penalty: Revocation of Service Company Status hereby applies for approval to operate as a servicing company for qualified self-insurers under the Michigan Workers' Disability Compensation Act and submits the following report in support of said application: 1. a. The name, address, etc., of the office that the Agency may contact for Service Company licensing and regulation concerns, including questions regarding this application. Title Phone # Fax # Contact Person Street/P O Box City State Zip Code b. The name, address, etc., of the MICHIGAN office pursuant to R408.43m (6). (Rule 408.43m (6) states, "A service company shall maintain adequate staff in the state. The service company shall authorize staff to act for the service company on all matters covered by the act and the rules of the bureau.") Title Phone # Fax # Contact Person Street/P O Box City State Zip Code 2. 3. 4. Applicant is: Federal I.D. Number: Is applicant a subsidiary? a. b. Individual Partnership Corporation LLC Yes No Parent Company is: Percent of voting stock owned by parent Address Address Address Address % Name Name Name Name 5. Name and address of the partners, officers or members. Title Title Title Title 6. Individual, partners, principal stockholders or principal managers and percentage of stock owned by each. % % % % WC-404 (Rev. 9/11) American LegalNet, Inc. www.FormsWorkFlow.com 7. Does the applicant seek approval to provide claims services for qualified self-insurers in the state of Michigan? Yes No If yes, the service company must provide the name of the principal individual the applicant will use to fulfill the requirement of Rule 13m regarding claims services, and a resume covering prior experiences must be attached to this application. Does the applicant seek approval to provide underwriting services for qualified self-insurers in the state of Michigan? Yes No If yes, the service company must provide the name of the principal individual the applicant will use to fulfill the requirement of Rule 13m regarding underwriting services, and a resume covering prior experiences must be attached to this application. Does the applicant seek approval to provide loss control services for qualified self-insurers in the state of Michigan? Yes No If yes, the service company must provide the name of the principal individual the applicant will use to fulfill the requirement of Rule 13m regarding loss control services, and a resume covering prior experiences must be attached to this application. Does applicant have in-house facility for providing loss data reporting for the client and the Agency? Yes If no, list the name of the facility that will be used to compile loss data. No 8. 9. 10. 11. 12. Attach a copy of the applicant's most recent annual financial statement (certified financial statements are preferred). Attach a copy of the applicant's standard service contract. (Must include provisions for handling claims to conclusion and reporting to the excess insurer. See sections d and e below.) NOTE: IF THE SERVICE COMPANY DEVIATES FROM THIS STANDARD CONTRACT FOR ANY MICHIGAN CLIENT, PRIOR WRITTEN APPROVAL MUST BE RECEIVED FROM THE MICHIGAN WORKERS' COMPENSATION AGENCY. In consideration of the privilege of being an approved service company, we hereby certify that: a. b. c. d. We will abide by all provisions of the Michigan Workers' Disability Compensation Act and Administrative Rules. We will promptly furnish all reports to the Workers' Compensation Agency which it may lawfully require including, upon request, a copy of our service agreement for each approved self-insurer that contracts for our services. In case of insolvency of a self-insured employer, we will make our records available to an agent of the Self-Insurers' Security Fund. Our contract for services complies with the Workers' Disability Compensation Act and the Administrative Rules including, but not limited to Rule 13m, which provides, in part, "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 the service company is relieved by the bureau, in writing, of the responsibility for handling claims." Pursuant to Rule 13m, the service company certifies that its standard service contract provides for the reporting to and placing on notice, the self-insurers' specific and/or aggregate excess insurer, of all claims, as required by the specific and/or aggregate excess insurance contracts purchased by the self-insurer. Should we deviate from the standard service contract, we will advise and request the Agency's approval before entry into such a contract. e. f. I affirm all information submitted as being true. BY:_____________________________________________ Type Name of Person Signing NOTARY SIGNATURE:_________________________________ COUNTY OF:_________________________________________ MY COMMISSION EXPIRES:____________________________ DATE:_______________________________________________ AFFIX STAMP: TITLE:__________________________________________ Title of Person Signing SIGNATURE: ___________________________________ WC-404 (Rev. 9/11) Print Save Document Reset American LegalNet, Inc. www.FormsWorkFlow.com WORKERS' COMPENSATION AGENCY R408.43m-EFFECTIVE MARCH 1, 2007 R 408.43m Servicing self-insured employers or groups; application; requirements; noncompliance. 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 contract with the individual or group self-insurer and shall satisfy the bureau that it has adequate facilities and competent staff with Michigan workers' compensation adjusting e xperience within the state to service a self-insured program in a man ner that fulfills the emplo yers'