Michigan Certificate Of Specific Or Aggregate Excess Liability Insurance (Self Insurer)

MICHIGAN CERTIFICATE OF SPECIFIC/AGGREGATE EXCESS LIABILITY INSURANCE TO: Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency Self-Insured Programs P.O. Box 30016 Lansing, Michigan 48909 This certifies that a workers' compensation excess liability insurance policy has been issued to the employers named below and the filing of this certificate is confirmation that the excess liability insurance policy identified below is effective on the date stated, that the policy form is approved for use in Michigan by the Insurance Commissioner and complies with all requirements in the Michigan Workers' Disability Compensation Act of 1969 and Administrative Rule 408.43k. Cancellation or intent to not renew the policy by the insurer or insured must be by courier, certified, or registered mail and sent to the Workers' Compensation Agency not less than 60 days prior to the cancellation or nonrenewal. Name of Insured Employers (List all self-insured employers, attach additional page if necessary) Name of Insurer Address Policy Number Effective Date Specific Policy Limit $ Retention $ Policy Term (Years) TERMS OF COVERAGE Aggregate Policy Limit $ Retention Percentage Minimum Retention $ Estimated Retention $ Policy Term (Years) (Insurer) (Authorized Signature (Rev. 8/11) American LegalNet, Inc. www.FormsWorkFlow.com