Self Insurers Claims Transfer Agreement

SELF-INSURER'S CLAIMS TRANSFER AGREEMENT It is agreed between self-insured employer new service company , old service company , and , that all workers' compensation files previously serviced by old service company , on behalf of self-insured employer for the , shall be transferred date self-insured period of date , through . to new service company Starting with the date of transfer of the claim files, new service company , will assume all further responsibility for the proper handling of these files, including reporting to and advising the specific and aggregate excess insurance carrier(s), in accordance with the excess insurance contracts in force for the respective self-insured periods. In addition to the files being transferred, , agrees to handle all future claims, pursuant to Rule 13m, reported new service company or re-opened for the self-insured period listed above. It is also agreed that all responsibility of old service company , for the future handling , of claims incurred in the above-mentioned self-insured period, will terminate effective the date of transfer of claims to . However, new service company new service company will not be responsible for any actions taken by old service company , while it was the . self-insured employer servicing company of record for It is also understood that representatives signing this document have full authority to act on behalf of their respective organizations and to enter into this agreement and fulfill its responsibilities and obligations provided, herein. Self-Insured Employer By: Signature New Service Company By: Signature Its: Title Its: Title Date Signed: Date Signed: Old Service Company By: Signature Its: Title Date Signed: IF THE OLD SERVICE WISHES TO BE RELIEVED FROM FUTURE HANDLING OF CLAIMS TO CONCLUSION, THE OLD SERVICE COMPANY MUST REQUEST ARELEASE FROM THIS RESPONSIBILITY BY LETTER WITH A COPY OFTHIS AGREEMENTATTACHED. (Revised 01/97) American LegalNet, Inc. www.FormsWorkFlow.com WORKERS' COMPENSATION AGENCY R408.43m-EFFECTIVE MARCH 1, 2007 R 408.43m Servicing self-insured employers or groups; application; requirements; noncompliance. Rule 13m. (1) An individual, partnership, limited liability company, or corporation that desires to engage in the business of providing 1 or more services for an individual self-insurer or a self-Insurers' group shall apply to the bureau before entering into a contract with the individual or group self-insurer and shall satisfy the bureau that it has adequate facilities and competent staff with Michigan workers' compensation adjusting experience within the state to service a self-insured program in a manner that fulfills the employers' obligations under the act and the rules of the bureau. Workers' compensation claims of Michigan individual or group self-insured employers shall be handled within the state of Michigan by its staff, except that the director, at his or her discretion, may permit an approved service company to handle the claims of a Michigan individual self-insurer outside of this state upon specific written request by the individual self-insurer and the service company. The request for permission shall set forth documentation sufficient to the agency that claims will be handled pursuant to Michigan law, administrative rules, and agency policy. The director will respond to the request in writing, giving the reasons for denial, or if approved, the conditions of approval. The approval may be withdrawn by the director at any time based upon the failure of the service company and/or employer to comply with the conditions of the approval. Service may include claims adjusting, loss control services, underwriting, and the capacity to provide required reporting. Any individual, partnership, limited liability company, or corporation that provides claims adjusting or loss control services to an approved self-insured employer, where the self-insured employer has designated within its own organization an individual to be responsible to the bureau for its claims program or loss control services, or both, shall not be considered a service company for purposes of this rule. (2) An applicant shall apply to the bureau for approval to act as a servicing company for self-insured employers or group funds on a form prescribed by the bureau. The application shall contain answers to all questions. An applicant shall give the answers under oath. The bureau shall approve the application prior to the service company entering into a contract with an approved self- insurer. Approval to act as a service company for self-insurers is granted for a period of 1 year and is subject to renewal annually. (3) If a service company seeks approval to service claims for self-insurers, then it shall submit proof that it has, within its organization at least 1 person who has the knowledge and Michigan workers' compensation adjusting experience necessary to handle claims involving the act. The service company shall attach a resume covering the principal person's background to the application of the service company. The principal individuals adjusting workers' compensation claims shall hold a current workers' disability compensation adjuster's license under chapter 12 of 1956 PA 218, MCL §500.1201. (4) If a service company seeks approval to provide underwriting service to self-insurers, then it shall submit proof that it has, within its organization or under contract on a full-time basis, at least 1 person who has the knowledge and experience necessary to provide underwriting services for workers' compensation excess liability insurance coverage. The service company shall attach a resume detailing the principal person's background to the application of the service company. (5) If a service company seeks approval to furnish loss control services to self-insurers, then it shall submit proof that it has, within its organization or under contract on a full-time basis, at least 1 person who has the knowledge and background necessary to adequately provide loss control and health services. (6) A service company shall maintain adequate staff in the state. The service company shall authorize staff to act for the service company on all matters covered by the act and the rules of the bureau. (7) A service company shall attach to the application a copy of its standard service agreement that it will enter into with self-insured employers or group funds. The service company shall certify, in writing, that the service agreement is