MICHIGAN WORKERS ' COMPENSATION PLACEMENT FACILITY

P. O. BOX 3337   •    LIVONIA, MI   48151-3337

PHONE (734) 462-9600    •    FAX (734) 462-9721

Internet WEB Site:  www.caom.com  • E-Mail:  caom@caom.com

January 26, 2001

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                                                   CIRCULAR LETTER #165

                                                  TO ALL PARTICIPANTS IN

Dear Member:

ACORD now has a Michigan Specific Application that may be used when applying for coverage to the Michigan Workers= Compensation Placement Facility. In addition to the application, there is also a Specific Person Exclusion Form exclusive to Michigan that will be used in conjunction with the application.

It is important to note that ACORD forms (application and exclusion) submitted to the Facility must be Michigan specific. Standard ACORD forms will not be accepted.

Sincerely,

Gary Thompson