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State of Michigan Workers Compensation Proposal - PDF

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					                  WORKERS’ COMPENSATION PROPOSAL INFORMATION - MICHIGAN

              PLEASE COMPLETE AND RETURN THIS FORM, ALONG WITH YOUR
             FACILITY’S MOST RECENT WC LOSS RUNS (THE LAST FIVE YEARS)
            AND CURRENT FINANCIAL STATEMENTS TO CAROLYN HALSTEAD AT:
      FINCOR HOLDINGS 6215 W. ST. JOSEPH LANSING MI 48917 FAX # 517-327-2528

Name of Entity to Be Covered:      _________________________________________________________
Federal Tax ID #:                  ______________________ # Of Employees: ____________________
Address:                           _________________________________________________________
City/State/Zip:                    _________________________________________________________
Name of Contact Person:            _________________________ Phone Number: ___________________
Current WC Renewal Date:           ____________ Effective Date Requested For Quote: ______________
# of Aircraft Exposures:           ____________ # of Vehicle Exposures: ________________________
Please list any other locations to be included in coverage (that are under the above Federal Tax ID #)
on the back of this form. Use a different form for each entity that has a DIFFERENT Federal Tax ID #
from the # listed above.

Projected Payroll for policy year to be quoted:
 8833--Hospital Professional        $__________            9040--Hospital All Other            $__________
 8810--Clerical                     $__________            9015--Janitorial, Non-Hospital      $__________
 8832--Physician's Offices          $__________            7380--Drivers                       $__________
 8835--Public Health Nursing                               Other                               $__________
       Home Health Care             $__________

  •Please provide, for the previous five year period, a list of all Workers’ Compensation claims filed. This
  should include all open and closed claims. Your current insurer or insurance agent can generate this
  report. (If you are unable to obtain these reports, please send a copy of the attached letter on corporate
  letterhead to the Compensation Advisory Organization authorizing them to release experience rating
  information.)

  •Audited payroll information by class code for each policy period for the last five years - please fill the
  information in the table below.

     Payroll Code           2006              2005              2004              2003               2002
           8833
           8810
           8832
           8835
           9040
           9015
           7380
        Other*
  *Please describe employees duties included here:

  ___________________________________________________________________________________

				
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