Michigan > Workers Comp
Self Insurer Application BWC-402 - Michigan
| Self Insurer Application Form. This is a Michigan form and can be used in Workers Comp . |
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Self-Insurer Applicant: Application for workers' disability compensation self-insured authority is made on Form WC-402. Questions 1through 10 must be completed. Requests for attached information as stated in questions 11 through 14 (on the back of the application) must be submitted with the application. Completed applications should be mailed to: Michigan Department of Energy, Labor & Economic Growth, Workers' Compensation Agency, Self-Insured Programs, P. O. Box 30016, Lansing, Michigan 48909. If you are using a courier service that requires a street address instead of a post office box number, please mail to: Michigan Department of Energy, Labor & Economic Growth, Workers' Compensation Agency, Self-Insured Programs, State Secondary Complex, GOB, 1st Floor, Wing B, 7150 Harris Drive, Lansing, Michigan 48913. Failure to complete, sign and notarize the application, or applications received without requested attachments, will result in the application being returned. Under normal circumstances, our review and decision process will take about 30 days from the date a completed application is received with all requested attachments. An applicant must demonstrate a reasonable financial position that will ensure all liabilities incurred under the Michigan Workers' Disability Compensation Act will be satisfied as prescribed in the Act. The applicant must have been "in business" five years. Multiple entities under one authority must be combinable pursuant to administrative rule 408.43. Generally, specific and aggregate excess insurance is required. Applicants, except governmental entities, will be required to post a bond or letter of credit. The minimum amount is $100,000. If the employer elects a letter of credit and it is subsequently not renewed or the proceeds from a draw are needed to pay any Michigan workers' disability compensation liability that is the employer's responsibility, the Agency will deposit all letter of credit proceeds with the State Treasurer and establish a trust. Upon termination of the trust, all remaining proceeds of a letter of credit plus any interest will be deposited in the Self-Insurers' Security Fund. In the event claims are filed against the employer with dates of injury within the self-insured period after termination of the trust, the Self-Insurers' Security Fund shall reopen the trust with funds not to exceed the letter of credit proceeds received from the trust upon termination. If the applicant requests combinable entities to be included under one self-insured authority, corporate guaranties for the compensation liability will be required. An approved service company for claims handling will be required unless the applicant can demonstrate it has competent staff and reporting capabilities to administer claims in-house. If the application is approved, it is approved contingent upon obtaining the requirements contained in the approval letter. The program must be initiated within 30 days from the date of the contingent approval letter or the approval expires. All requirements must be furnished before an effective date will be granted. Self-insured authority is evaluated annually. There is no substitute for a demonstration of reasonable solvency and ability to pay claims as required in the Act. A renewal application, WC-402R, must be filed 30 days prior to the renewal date. Copies of documents required to be filed by approved applicants are attached. If we can be of assistance in the completion of forms or answer any questions about the approval process, please contact our office at 517-3221868. Attachments American LegalNet, Inc. www.FormsWorkFlow.com WORKERS' DISABILITY COMPENSATION SELF-INSURER APPLICATION Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency Self-Insured Programs 7150 Harris Drive (48913) PO Box 30016 Lansing, Michigan 48909 Authority: Completion: Penalty: Workers' Disability Compensation Act of 1969, as amended Mandatory Denial AGENCY USE ONLY APPROVED DENIED DATE DIRECTOR, BWC LOGGED The Department of Energy, Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, height, weight, or political belief. 1. 2. Employer (legal name) Employer's address City Street State Zip 3. 4. 5. 6. 7. Employer's legal structure Corporation Partnership Governmental Entity Other LTD Liability Co. Employer's federal identification number Employer's business was chartered under the laws of the state of Employer has Number State on Date total employees. Number of Michigan employees Employer representative responsible for the self-insured program Name Title Mailing Address City Street State Zip Telephone ( 8. 9. 10. ) Fax ( ) Designated service company Requested effective date for program, if approved Loss history (Michigan only) Liability Period From To Total Michigan Payroll Total Incurred Paid Reserve Losses evaluated at WC-402 (1/09) American LegalNet, Inc. www.FormsWorkFlow.com 11. 12. 13. 14. 15. 16. Attach a list of all subsidiaries/affiliates you are requesting to be self-insurers under the applicant's approval. The name, address, FEIN, number of employees and relationship to the applicant pursuant to R408.43(3) must be furnished for each employer to be self-insured in this program. If the applicant and other employers operate at more than one location, all addresses must be furnished. Attach a current compensation loss summary, by year, that supports at least the three previous years' loss experience as reported in number 10 on the front of this form. Loss summaries must clearly show paid, reserves and total incurred by year. Attach the quote for excess insurance you propose to purchase. Attach applicant's most recent annual financial statements. If statements are more than six months old, include an interim statement, if available. A five-year summary showing sales, operating income, net income, working capital and equity is required if it is not included in the current financial statements. Applicant may attach any information in addition to the above requested documents that explains or supports the financial position demonstrated, the ability to pay claims as a self-insurer, the loss experience, or the relationship of the applicants. Applicant must contract with an agency-approved service company or provide documentation that demonstrates it has within its own organization ample facilities and competen
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