Compensation Advisory Organization of Michigan

No Experience to Report Verification Form

This form is to provide CAOM with positive confirmation that a carrier has no experience to report under a given call(s). Submit ONE form showing all calls in which you indicate no experience to report.

Carrier(s)*
Carrier Code  Date
Submitted by
Title    Phone Number
Financial Call Call Number No Experience
Policy Year 3
Assigned Risk Policy Year 3A
Accident Year 5
Assigned Risk Accident Year 5A
Reconciliation Report 8
Countrywide Loss Adjustment Expense 19

*List all carrier names and carrier codes for group reporting