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Michigan Forms

18 State Forms found

name	number	revision	print or send online
Carrier's Explanation of Benefits	WC-739	(Rev. 8/19)
APPLICATION FOR CERTIFICATION OF A CARRIER’S PROFESSIONAL HEALTH CARE REVIEW PROGRAM	WC-590	(Rev. 8/19)
GROUP SELF-INSURER APPLICATION	WC-402GR	(Rev. 8/19)
Group Self-Insurer Application Packet	WC-402G	(Rev. 8/19)
INSURER’S NOTICE OF NAME OR ADDRESS CHANGE	WC-403	(Rev. 8/19)
LETTER OF CREDIT INFORMATION - MEMORANDUM OF UNDERSTANDING	No Form Number	(Rev. 8/19)
MICHIGAN CERTIFICATE OF SPECIFIC/AGGREGATE EXCESS LIABILITY INSURANCE	No Form Number	(Rev. 8/19)
MICHIGAN CONTINUOUS SURETY BOND	No Form Number	(Rev. 8/19)
SELF-INSURED GROUP NOTICE OF TERMINATION OF MEMBERSHIP	WC-651	(Rev. 8/19)
SELF-INSURED GROUP NOTICE OF ACCEPTANCE OF MEMBERSHIP	WC-650	(Rev. 8/19)
Self-Insurer Application Packet	WC-402	(Rev. 8/19)
SELF-INSURER REQUEST TO ADD OR DELETE SUBSIDIARY-AFFILIATE	WC-402A	(8/19)
SELF-INSURER’S CLAIMS TRANSFER AGREEMENT	No Form Number	(Revised 08/19)
NOTICE OF TERMINATION OF LIABILITY	WC-401	(Rev. 8/19)
APPLICATION FOR FTS USER ACCOUNT-WC Claims Mailbox	WC-460	(11/20)

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Disclaimer: These forms may not be the most recent version. Michigan may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.

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