Michigan > Workers Comp
Application For Membership In Group Of Self Insurers BWC-402G - Michigan
| Application For Membership In Group Of Self Insurers Form. This is a Michigan form and can be used in Workers Comp . |
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SAMPLE Page 1 of 5 Revised 05/03 APPLICATION FOR MEMBERSHIP IN THE NAME OF THE GROUP Applicant Name Mailing Address (Street No. and Name) City, State ZIP Code Phone # Fax # Federal Tax ID# Date Coverage Begins: ( ) ( ) Description of business: Location and names of operations other than the above: Michigan Employment Security Commission number: Number of employees regularly employed in Michigan: Total payroll for all Michigan employees for the past year: Above company has been in existence in the state of Michigan since: List all names of partners, corporate officers, or directors: Name Office/Title Name Office/Title Name Office/Title Name Office/Title 1. Are you a division or subsidiary of a parent corporation? Yes No If yes, please explain 2. Years under present ownership: 3. Does your business have locations or job sites outside the state of Yes No If yes, please explain Michigan? 4. Do any of the companys employees travel outside the state of Yes No If yes, please explain Michigan on business of the employer member? 5. Current workers compensation carrier: PLEASE NOTE: If you answered yes to question #3, your company may have potent ial liability that will not be covered by this group self-insurer. You are cautioned to make appropriate arrangements to obtain the necessary insurance to cover those exposures. Explanations: (Attach additional sheets if necessary) BWC-402G (05/03) <<<<<<<<<********>>>>>>>>>>>>> 2 SAMPLETHE NAME OF THE GROUP Page 2 of 5 Revised 05/03Complete this section if there are any affiliated companies that will be insured under this group. The signature of the corporateofficer of these affiliated companies indicates that the companies named on this form are jointly and severally liable in r egard to all of theterms and conditions as described in this application. Company Mailing Address (Street No. and Name) City, State ZIP Code Phone # Fax # Federal Tax ID# Description of business: Location and names of operations other than the above: Michigan Employment Security Commission number: Number of employees regularly employed in Michigan: Total payroll for all Michigan employees for the past year: Above company has been in existence in the state of Michigan since: SIGNATURE OF CORPORATE OFFICER: Company Mailing Address (Street No. and Name) City, State ZIP Code Phone # Fax # Federal Tax ID# Description of business: Location and names of operations other than the above: Michigan Employment Security Commission number: Number of employees regularly employed in Michigan: Total payroll for all Michigan employees for the past year: Above company has been in existence in the state of Michigan since: SIGNATURE OF CORPORATE OFFICER: Company Mailing Address (Street No. and Name) City, State ZIP Code Phone # Fax # Federal Tax ID# Description of business: Location and names of operations other than the above: Michigan Employment Security Commission number: Number of employees regularly employed in Michigan: Total payroll for all Michigan employees for the past year: Above company has been in existence in the state of Michigan since: SIGNATURE OF CORPORATE OFFICER: APPLICANT NAME: BWC-402G (05/03) <<<<<<<<<********>>>>>>>>>>>>> 3 SAMPLETHE NAME OF THE GROUP Page 3 of 5 Revised 05/03 WAGE AND LOSS HISTORY DATA SHEET Estimated annual payrolls by specific industry code (S.I.C.) classific ation: Class Code Classification Estimated Annual Payroll CLAIMS EXPERIENCE Accident experience for twelve months preceding this application: Number of deaths: Number of permanent and total disabilities: Number of cases of specific loss: Number of injuries causing 7 or more days of disability: Claims experience over the past five years: From To Gross Payroll Paid Claims Reserves Total IncurredLosses in excess of $10,000 over the past five years: Date Injury Total Amount Open or Closed BWC-402G (05/03) <<<<<<<<<********>>>>>>>>>>>>> 4 SAMPLE THE NAME OF THE GROUP Page 4 of 5 Revised 05/03STATEMENT OF FINANCIAL CONDITION OF: (APPLICANT) Attach annual report, audited financial report, or report prepared for o ther regulatory agencies Financial Statement: (Required by the Michigan Department of Consumer & Industry Services) Please provide a copy of your most current balance sheet or have your bookkeeper complete and sign the form below. Information stated below is confidential and will be viewed only by the fund administrator and Bureau. Current Year: _________________ 20__________ STATEMENT OF ASSETS & LIABILITIES Assets: Current Assets Cash on Hand in Banks $ Stocks & Bonds Notes & Accounts Receivable Inventories Other Current Assets Total Current Assets $ Other Assets Properties, Building & Equipment $ Good Will Other Total Other Assets $ Total Assets $ Liabilities: Current Liabilities Accrued Payroll $ Trade Accounts Payable Notes Payable, short-term Taxes Payable Total Current Liabilities $ Other Liabilities Notes Payable, long-term $ Mortgages Payable Bonds Payable Total Other Liabilities $ Total Liabilities $ Capital Capital Stock $ Paid in Surplus Retained Earnings Total Capital $ Total Capital & Liabilities $ Signature Mailing Address (Street No. and Name) City, State ZIP Code Phone # ( ) BWC-402G (05/03) <<<<<<<<<********>>>>>>>>>>>>> 5 SAMPLE THE NAME OF THE GROUP Page 5 of 5 Revised 05/03 TheApplicant hereby certifies, warrants and represents that the financial s tatement included herewith and signedby the Applicant and the payroll information provided herein are accurate and true as of the date of this application and that the Applicant will provide ___________________________________________(name of group) (the "Group") with such other information required to qualify the Applicant with the applicable state authorities or other such persons designated by the Group. The Applicant warrants and represents that the Applicant will report all payroll of any kind, whether paid in cash, by check, or any other method, to the Group period ically, when requested, and agrees to make available all pertinent records at such reasonable times as requested. We hereby formally apply for workers disability compensation self-insurer coverage in the Group, to be effective 12:01 a.m. on the effective date given by the Michigan Bureau of Workers Compensation on the application and Form 650, following acceptance by the board of trustees or their design ated representative. With acceptance and approval of the application, the Applicant hereby constitutes and appoints the Gr oup and/or its designated
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