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Worker's Compensation Agency

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• DIFS Issues Bulletin Regarding Insurance Coverage PDF icon

• Change to Agency Online Fill-In Forms

• Agency Communication Regarding Insurers with a Service Company or Third Party as Claims Administrator

Forms & Publications

• WC-402 (8/11) Self-Insurer Application Packet (fill-in form) PDF icon

• WC-402A (8/11) Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form) PDF icon

• WC-402G (9/11) Group Self-Insurer Application Packet PDF icon

• WC-402GR (9/11) Group Self-Insurer Application (fill-in form) PDF icon

• WC-404 (9/11) Service Company Application (fill-in form) PDF icon

• WC-650 (9/11) Self-Insured Group Notice of Acceptance of Membership (fill-in form) PDF icon

• WC-651 (9/11) - Notice of Termination of Membership (fill-in form) PDF icon

• Letter of Credit/Memorandum of Understanding (8/11) (fill-in form) PDF icon

• Michigan Continuous Surety Bond (8/11) (fill-in form) PDF icon

• Michigan Certificate of Specific/Aggregate Excess Liability Insurance (8/11) (fill-in form) PDF icon

• Self-Insurer's Claims Transfer Agreement (fill-in form) 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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