Calendar Year 2016 Indemnity Request
The Second Injury Fund; Silicosis, Dust Disease and Logging Industry Compensation Fund; and the Self-Insurers' Security Fund are preparing to make the 2017 assessments in accordance with Chapter 5, Section 551 of the Workers' Disability Compensation Act of 1969. In order to properly calculate each fund's assessment, it is necessary that all carriers provide their calendar year indemnity payments.
Please report the total Michigan workers' compensation benefits, including redemption agreements, but excluding medical benefits, rehabilitation payments, and funeral costs, paid by your company during calendar year 2016. Please note that the amount you report should not include monies reimbursed by the Second Injury Fund; the Silicosis, Dust Disease and Logging Industry Compensation Fund; or the Compensation Supplement Fund. If your records are not complete, please provide an estimate.
The form must be completed and returned to the Funds Administration office by February 28, 2017. You may send your response by regular mail, by fax to 517-284-8890, or by e-mail to firstname.lastname@example.org.
Self-Insurers (Individual and Group)
Self-Insurers should include all subsidiaries covered under your self-insurance approval, during calendar year 2016. If you are no longer a self-insured employer in Michigan, but paid on claims incurred during your prior self-insurance program in calendar year 2016, please report this amount. If you have various periods of self-insurance coverage handled by either you or service organizations, please report to us the combined total payment for calendar year 2016.
Because many self-insured employers have used numerous service organizations, the assessment is sent directly to the self-insured employer. It is your responsibility to collect the necessary information and to complete the form.
If you write deductible workers' compensation policies in Michigan, you are responsible for reporting the payments that are the obligation of your policy holders, as well as your payments.
If you have any questions regarding this reporting requirement, please call Allison Kelly at 517-284-8871 or e-mail at email@example.com.
Click below the the 2016 Indemnity Request Form: