Form Ocr 400 - Form For Insurer'S Notice Of Issuance Of Policy
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2OCR 400
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INSURER’S NOTICE OF ISSUANCE OF POLICY
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
P O Box 30016, Lansing, MI 48909
A separate Form 400 is required for
each legal entity insured under a policy
INSTRUCTIONS: SEE REVERSE SIDE
1. Employer Federal I.D. Number
2. Name of Business
3. Parent Co. Federal I.D. Number
4. Owner of Business (If applicable)
5. Mailing Address (Street No. and Name)
City
State
ZIP Code
6. Type of Organization
e. Joint Venture
c. Individual
g. Limited Liability Company
a. Corporation
d. Public Employer
b. Partnership
f. Other/Trust
7. NAIC Carrier I.D. Number (9 digits)
8. ZIP Code of Issuing Office
9. Name of Insurance Company
10. Policy Number
11. Effective Date of Coverage
12. Annual Payroll in Dollars
13. Michigan Class Code
14. Number of Employees
Pursuant to the Workers’ Disability Compensation Act, this is to certify that the above referenced employer has been issued a policy of
insurance by the above carrier. This policy covers all the liability imposed upon the employer by the provisions of the Michigan Workers’
Disability Compensation Act for all employees in any and all of the employer’s businesses.
15. Authorized Signature
Date
Please list below additional names and/or addresses for the Federal I.D. Number listed in Item #1. (A separate Form 400
16.
is required for each legal entity insured under a policy.)
Name of Business
Name of Business
Address (Street No. and Name)
Address (Street No. and Name)
City
State
ZIP Code
City
State
ZIP Code
Name of Business
Name of Business
Address (Street No. and Name)
Address (Street No. and Name)
City
State
ZIP Code
City
State
ZIP Code
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable
Authority:
Workers’ Disability Compensation Act 418.625(1); R408.41
accommodations are available upon request to individuals with disabilities.
Completion:
Mandatory
WC-400 (Rev. 9/16) FRONT
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