Workers Disability Compensation Self-Insurer Application {WC-402}

Self-Insurer Applicant: Application for workers' disability compensation self-insured authority is made on Form WC-402. Questions 1through 10 must be completed. Requests for attached information as stated in questions 11 through 14 (on the back of the application) must be submitted with the application. Completed applications should be mailed to: Michigan Department of Licensing and Regulatory Affairs, Workers' Compensation Agency, Self-Insured Programs, P. O. Box 30016, Lansing, Michigan 48909. If you are using a courier service that requires a street address instead of a post office box number, please mail to: Michigan Department of Licensing and Regulatory Affairs, Workers' Compensation Agency, SelfInsured Programs, 2501 Woodlake Circle, Okemos, MI 48864. Failure to complete, sign and notarize the application, or applications received without requested attachments, will result in the application being returned. Under normal circumstances, our review and decision process will take about 30 days from the date a completed application is received with all requested attachments. An applicant must demonstrate a reasonable financial position that will ensure all liabilities incurred under the Michigan Workers' Disability Compensation Act will be satisfied as prescribed in the Act. The applicant must have been "in business" five years. Multiple entities under one authority must be combinable pursuant to administrative rule 408.43. Generally, specific and aggregate excess insurance is required. Applicants, except governmental entities, will be required to post a bond or letter of credit. The minimum amount is $100,000. If the employer elects a letter of credit and it is subsequently not renewed or the proceeds from a draw are needed to pay any Michigan workers' disability compensation liability that is the employer's responsibility, the Agency will deposit all letter of credit proceeds with the State Treasurer and establish a trust. Upon termination of the trust, all remaining proceeds of a letter of credit plus any interest will be deposited in the Self-Insurers' Security Fund. In the event claims are filed against the employer with dates of injury within the self-insured period after termination of the trust, the Self-Insurers' Security Fund shall reopen the trust with funds not to exceed the letter of credit proceeds received from the trust upon termination. If the applicant requests combinable entities to be included under one self-insured authority, corporate guaranties for the compensation liability will be required. An approved service company for claims handling will be required unless the applicant can demonstrate it has competent staff and reporting capabilities to administer claims in-house. If the application is approved, it is approved contingent upon obtaining the requirements contained in the approval letter. The program must be initiated within 30 days from the date of the contingent approval letter or the approval expires. All requirements must be furnished before an effective date will be granted. Self-insured authority is evaluated annually. There is no substitute for a demonstration of reasonable solvency and ability to pay claims as required in the Act. A renewal application, WC-402R, must be filed 30 days prior to the renewal date. Copies of documents required to be filed by approved applicants are attached. If we can be of assistance in the completion of forms or answer any questions about the approval process, please contact our office at 517-284-8939. Attachments American LegalNet, Inc. www.FormsWorkFlow.com WORKERS' DISABILITY COMPENSATION SELF-INSURER APPLICATION Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency Self-Insured Programs PO Box 30016 Lansing, MI 48909 AGENCY USE ONLY APPROVED ____________ DENIED _______________ DATE _________________ DIRECTOR, WCA _______ LOGGED ______ _______ Authority: Completion: Penalty: Workers' Disability Compensation Act of 1969, as amended Mandatory Denial LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. 1. 2. Employer (legal name) Employer's address Street _______________________________________________________________________________________________________________________________________________________ City State Zip 3. 4. 5. 6. 7. Employer's legal structure Corporation Partnership Governmental Entity Other LTD Liability Co. Employer's federal identification number Employer's business was chartered under the laws of the state of State on Date Employer has Number total employees. Number of Michigan employees Employer representative responsible for the self-insured program Name Title Mailing Address Street ___________________________________________________________________________ City State Zip Telephone ( 8. 9. 10. ) Fax ( ) ____ Designated service company Requested effective date for program, if approved Loss history (Michigan only) Total Michigan Payroll Total Incurred Paid Reserve Liability Period From To Losses evaluated at ________ WC-402 (Rev. 8/11) American LegalNet, Inc. www.FormsWorkFlow.com Attach a list of all subsidiaries/affiliates you are requesting to be self-insurers under the applicant's approval. The name, address, FEIN, number of employees and relationship to the applicant pursuant to R408.43(3) must be furnished for each employer to be self-insured in this program. If the applicant and other employers operate at more than one location, all addresses must be furnished. 12. Attach a current compensation loss summary, by year, that supports at least the three previous years' loss experience as reported in number 10 on the front of this form. Loss summaries must clearly show paid, reserves and total incurred by year. 13. Attach the quote for excess insurance you propose to purchase. 14. Attach applicant's most recent annual financial statements. If statements are more than six months old, include an interim statement, if available. A five-year summary showing sales, operating income, net income, working capital and equity is required if it is not included in the current financial statements. 15. Applicant may attach any information in addition to the above requested documents that explains or supports the financial position demonstrated, the ability to pay claims as a self-insurer, the loss experience, or the relationship of the applicants. 16. A