MICHIGAN WORKERS' COMPENSATION PLACEMENT FACILITY
REQUEST FOR ASSIGNED RISK DEPOPULATION REPORT
NAME ____________________________________________________________________
TITLE/DEPARTMENT: _______________________________________________________
AGENCY/COMPANY: _______________________________________________________
STREET ADDRESS: _________________________________________________________
CITY, STATE, ZIP: __________________________________________________________
PHONE #: __________________________ FAX #: ________________________________
| INDICATE SORT PREFERENCE: |
||
|---|---|---|
| __ | Standard | Expiration date, primary sort / Premium , secondary sort |
| __ | Alternative | City, primary sort / Premium, secondary sort |
COST: $50.00 Per Quarter |
||
| __ | 1st Quarter | Issued in January - April, May and June expirations |
| __ | 2st Quarter | Issued in April - July, August and September expirations |
| __ | 3st Quarter | Issued in July - October, November and December expirations |
__ |
4th Quarter | Issued in October - January, February and March expirations |
Request must be accompanied by a check made payable to The
Michigan
Workers' Compensation Placement Facility (M.W.C.P.F).
P.O. Box 3337, Livonia, Ml 48151-3337 (734) 462-9600 Fax (734) 462-9721