Insurers Notice Of Name Or Address Change {WC-403}

INSURER'S NOTICE OF NAME OR ADDRESS CHANGE Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P.O. Box 30016, Lansing, Michigan 48909 INSTRUCTIONS: SEE REVERSE SIDE SECTION A Employer Federal ID Number Policy Number Name of Business SECTION B FORMER NAME/ADDRESS OF BUSINESS Name of Business Address (Street Number and Name) City, State, ZIP Code Effective Date of Change CURRENT NAME/ADDRESS OF BUSINESS Name of Business Address (Street Number and Name) City, State, ZIP Code SECTION C PLEASE LIST BELOW ADDITIONAL NAMES AND/OR ADDRESSES FOR THE FEDERAL ID NUMBER LISTED IN SECTION A Name of Business Address ( Street Number and Name) City, State, ZIP Code Effective Date of Change Reason for Change Name of Business Address ( Street Number and Name) City, State, ZIP Code Effective Date of Change Reason for Change Name of Business Address ( Street Number and Name) City, State, ZIP Code Effective Date of Change Reason for Change Name of Business Address ( Street Number and Name) City, State, ZIP Code Effective Date of Change Reason for Change SECTION D Name of Insurance Company ZIP Code of Issuing Office Authorized Signature NAIC Carrier ID Number (9 digits) Telephone Number (including area code) Date LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Authority: Completion: Penalty: Workers' Disability Compensation Act of 1969 418.625; R408.41 Mandatory Failure to file is punishable under MCLA 418.631 WC-403 (Rev. 9/13) American LegalNet, Inc. www.FormsWorkFlow.com Purpose of Form WC-403 To notify the Michigan Workers' Compensation Agency of a name and/or address change of an employer. To notify the agency of an addition or deletion of a division of the employer. To notify the agency of a name or address change of a division of an employer. INSTRUCTIONS FOR COMPLETION SECTION A Employer's Federal Identification Number Name of Business Policy Number Enter the employer's Federal Identification Number. This is a 9-digit number. If an individual (sole proprietor) does not have a Federal Identification Number, the Social Security Number of the individual will be accepted. Enter complete name of business, including assumed name. Complete number. SECTION B This section will be used to change the name and/or address of the employer. If used for a name change, this section must include the previous name of the employer and the new name of the employer. Name of Business Address Effective Date of Change Enter complete name of the employer. The complete address of the business, including city, state, and ZIP code, must be identified. Date that the name and/or address change is effective. SECTION C This section will allow for the addition, deletion, change of name, or change of address of a division. A division is an operation of the employer that operates under the same Federal Identification Number but under an assumed name. If used for a name change to a division, then this section must include previous name of the employer and the new name of the employer. Name Address Effective Date of Change Reason for Change Enter the complete name of the division. The complete address of the business, including city, state, and ZIP code, must be identified. Use street address, not post office box number. The date that the addition, deletion, or change of name and/or address is effective. Addition of a division, deletion of division; e.g. due to sale of division, division no longer in business, etc.; or change; e.g. name change, address change, etc. SECTION D This section will identify the insurance company making the change. Name of Insurance Company NAIC Carrier ID No. Telephone Number ZIP Code of Issuing Office Authorized Signature Complete name of insurance company. National Association of Insurance Commissioners' (NAIC) ID number (5 digits) followed by the group number (4 digits) of the insurance company. Telephone number of office filing the form. Show the complete ZIP code for the insurance company office issuing this form. Must have an original signature in black or blue ink. Typed signature is not acceptable. Include the date the form was signed. WC-403 (Rev. 9/13) American LegalNet, Inc. www.FormsWorkFlow.com