Michigan > Workers Comp
Insurers Notice Of Issuance Of Policy WC-400 - Michigan
| Insurers Notice Of Issuance Of Policy Form. This is a Michigan form and can be used in Workers Comp . |
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INSURER'S NOTICE OF ISSUANCE OF POLICY INSTRUCTIONS: SEE REVERSE SIDE A separate Form 400 is required for each legal entity insured under a policy American LegalNet, Inc. www.FormsWorkFlow.com Purpose of Form WC-400: When Required: General Guidelines for Completing Form WC-400: should not INSTRUCTIONS FOR COMPLETION Item #1 Employer Federal I.D. Number (9 digits) required Item #2 Name of Business same Item #3 Parent Co. Federal I.D. Number Item #4 Owner of Business (If applicable) Item #5 Mailing Address Item #6 Type of Organization Item #7 NAIC Carrier I.D. Number (9 digits) Item #8 ZIP Code of Issuing Office Item #9 Name of Insurance Company Item #10 Policy Number Item #11 Effective Date of Coverage Item #12 Annual Payroll in Dollars Item #13 Michigan Class Code Item #14 Number of Employees Item #15 Authorized Signature Item #16 Additional Names and/or Addresses of the Business American LegalNet, Inc. www.FormsWorkFlow.com
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