Forms

 
 
Assigned Risk
Application for Assigned Risk Workers' Compensation Insurance
To be filled out by an agent and/or employer requesting assigned risk coverage through the Michigan Workers' Compensation Placement Facility
Specific Person Exclusion/Certified Resolution/Consent Form
Specific Person Exclusion: To be filled out by a person or persons eligible for exclusion from coverage under the workers' compensation law. *A written signature is required.
Certified Resolution/Consent Form: A corporation or LLC acknowledgement that a certain person or persons are requesting exclusion from coverage provided by the workers' compensation policy. *A written signature is required.
ERM-14 Confidential Request for Information
Details the ownership of an entity or entities. A written signature is required.
Independent Contractor Worksheet
A form to be submitted to the assigned carrier for the policyholder's audit. This form is to be completed by the party claiming to be an independent contractor.
Supplemental Worksheet - Truckers
To be filled out in addition to the INDEPENDENT CONTRACTOR WORKSHEET by a sole proprietor owner operator truck driver.
Financial Data Calls
MIFDRA Contact Person Form
Designates a contact between a carrier and CAOM for communication regarding financial calls.
No Experience to Report Verification Form (for MIFDRA)
Provides CAOM with confirmation that a carrier has no experience to report under a given call.
Experience Rating
Rating Values Form
To be used when filing annual experience rating factors.
Experience Modification Web Service Sign-Up
Order form to sign up for the online experience modification web look-up service.
Circular Letters
Circular Letter Notification Form
To be submitted in order to receive circular letter notifications.