Application For FTS User Account (Carriers And Self Insured Employers) {WC-460}

APPLICATION FOR DEG USER ACCOUNT Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 INSTRUCTIONS The Michigan Workers' Compensation Agency is now accepting from carriers and individual and group self-insurers only, forms 400, 401, 100, 107, and 701 via upload through Michigan Data Exchange Gateway, a secure website. All uploaded forms must be single page documents, no attachments can be included. All forms with attachments must continue to be sent by regular mail. Multiple single page documents may be submitted in a single upload as long as each individual document is identified by the form number at the beginning of each document name. Uploaded forms will only be accepted from carriers approved to write workers' compensation in Michigan, approved self-insurers and approved group self-insurers, or servicing agents approved to act on their behalf or managing general agent (MGA) filing on behalf of a company. An insurance carrier group can have no more than one user account. If you are interested in participating, please complete the application form and email it to kurikesuj@michigan.gov. Once the form is received and approved you will receive the necessary instructions on how to send forms via Michigan Data Exchange Gateway including User ID, password, etc. Sections 7, 8, and 9 must identify carrier, self-insurer, group self-insurer's or managing general agent (MGA) direct contact information, not service company information. Sections 10-14 are to be completed by approved self-insured employer or group fund only. You must also submit a completed form WC-450, Application for Authorization by Self-Insured Employer or Group Fund for Servicing Agency DEG User Account. 1. Carrier, Self-Insurer, Group Self-Insurer or MGA Name 3. Street Address 5. State 7. Contact Name 8. Contact Email 9. Contact Phone Number 2. NAIC or Self-Insurer ID Number 4. City 6. ZIP Code Approved service company filing on behalf of self-insured employer or group fund. 10. Self-Insurer Service Company Name (if applicable) 12. Service Company Contact Name 13. Service Company Contact Email 14. Service Company Contact Phone Number 11. Self-Insurer Service Company ID Number This form must be promptly updated whenever any information indicated above changes. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-460 (12/16) American LegalNet, Inc. www.FormsWorkFlow.com