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Workers' Compensation AgencyMichigan.gov, Official Web Site for the State of Michigan
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Forms & Publications

• WC-402 (1/09) Self-Insurer Application Packet PDF icon

• WC-402A (1/09) Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form) PDF icon

• WC-402G (1/09) Group Self-Insurer Application Packet PDF icon

• WC-402GR (1/09) Group Self-Insurer Application (fill-in form) PDF icon

• WC-404 (1/09) Service Company Application (fill-in form) PDF icon

• WC-650 (1/09) - Self-Insured Group Notice of Acceptance of Membership (fill-in form) PDF icon

• WC-651 (1/09) - Notice of Termination of Membership (fill-in form) PDF icon

• Letter of Credit/Memorandum of Understanding (1/09) (fill-in form) PDF icon

• Michigan Continuous Surety Bond (1/09) PDF icon

• Michigan Certificate of Specific/Aggregate Excess Liability Insurance (1/09) PDF icon

• Self-Insurer's Claims Transfer Agreement PDF icon

Other Information

• Individual Self-Insured Employer List

• Active Self-Insured Group List

• Service Company List

• Self-Insured Division Information PDF icon


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