Forms

    Click on the following form titles to view and/or print. See below for descriptions.

1. Information & Procedures Handbook Order Form   PDF Version  Word Version
   The Information & Procedures Handbook is updated annually to include changes in procedures and rate revisions for the following year. The updates are traditionally mailed the beginning of December.

2. Michigan Application for Workers' Compensation Insurance  PDF Version    
   A form to be filled out by an agent and/or employer requesting assigned risk coverage through the Michigan Workers’ Compensation Placement Facility.

3. Specific Person Exclusion/Certified Resolution/Consent Form  PDF Version  Word Version
   A form to be filled out by an individual or individuals eligible for exclusion from coverage under the workers’ compensation policy. An entity's acknowledgment that certain individuals are requesting exclusion from coverage provided by the workers' compensation policy.

4. ERM-14 Confidential Request for Information  PDF Version  Word Version
   A document detailing the ownership of an entity or entities.

5. Request for Assigned Risk Depopulation Report
   A quarterly report indicating risk information which may assist an agent to place a current assigned risk pool employer into the voluntary market.

6. Michigan Financial Calls  A list of Financial Call forms in Excel to be filled out and e-mailed, faxed or mailed to us.

7. Mod Quote Form A form to be filled out that e-mails us a request for a faxed mod quote form.

With a non-compatible browser use the following steps
to download "form file" in either MS WORD or Adobe Acrobat Reader:

1. Decide which form (listed below) you need.

2. Click on the file (in the two right hand columns) you wish to download (select either Microsoft Word or Adobe Acrobat Reader). You can then select a directory to download to. Note: If you don't have "Microsoft Word" "Click Here" to download Microsoft Word Viewer. (This program will run in any Windows version.)

3. After file is downloaded go to that directory, click on that file and a screen will pop up. Select the directory where you want the file to go and click on "unzip". It will now be a usable "Word" or "WordPerfect" file

4. Start your word processor and load file for printing.

5. Complete the form, and please follow any other instructions that are specific to that form.

6. Mail to: P.O. Box 3337 Livonia, MI 48151-3337

7. Fax to: (734) 462-9721 (Note: If a check is to be sent with that specific form, please mail.)