Self-Insurer Request To Add Or Delete Subsidiary/affiliate
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SELF-INSURER REQUEST
TO ADD OR DELETE SUBSIDIARY/AFFILIATE
Michigan Department of Licensing and Regulatory Affairs
Employer Records
OFFICE USE ONLY
Workers’ Compensation Agency
Approved/Denied
Self-Insured Programs
Effective
PO Box 30016
Lansing, MI 48909
_____________
______________
Name of Current Self-Insurer
Federal ID #
1. This is an
Addition
Deletion
2. Subsidiary/Affiliate
Name
Federal ID #
Address
City
State
Zip Code
3. Entity to be added was chartered under the laws of the state of ___________________________on______/________/_____.
4. Michigan locations (attach additional sheets if necessary)
Name
Federal ID #
Address
City
State
Zip Code
5.
Effective date requested: _____/_____/_____
6. Reason for addition/deletion (“acquisition,” “out of business,” “sold,” etc.)
FOR ADDITIONS ONLY: COMPLETE THIS SECTION
R 408.43(3) of the Worker’s Disability Compensation Act of 1969, as amended states: “Separate legal entities may be self-
insured under a single authority if they are majority-owned by the self-insured entity submitting the application or if the same
person or group of persons owns a majority interest in each entity on a single application.”
7. Does the existing self-insured employer have a majority ownership in the entity that will become self-insured?
Yes
No
If Yes, % of ownership_________%
8. In the alternative, does the same person or group of persons own a majority interest in both the current self-insured and
the entity to be added?
Yes
No
If Yes, attach additional sheets that list the person or group of persons
who own a majority interest in each entity and their % of ownership.
NOTE: If questions 7 and 8 have both been answered: “No,” the entity does not qualify for self-insured
authority with the current self-insured.
9. Will a claims payment guaranty be furnished by parent or affiliate if required?
Yes
No
10. Total number of Michigan employees of entity to be added _______________
11. Estimated amount of Michigan annual payroll for entity to be added $_________________
12. If aggregate excess insurance is required for current program, estimate increase in retention $______________
NOTE: Please attach financial statements for the new employer if not consolidated in financial statements of the
primary self-insured employer.
AUTHORIZED SIGNATURE
TITLE
DATE
Authority:
Worker’s Disability Compensation Act of 1969, as amended
LARA is an equal opportunity employer/program. Auxiliary aids, services and other
Completion:
Mandatory
reasonable accommodations are available upon request to individuals with disabilities.
Penalty:
Denial/Termination of Self-Insured
WC-402A (8/11)
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