Assigned Risk
NP-10M Michigan Petition For Servicing Carrier Allowance On Uncollected Premium
To be filled out by a servicing carrier to petition the Pool for servicing carrier allowance on uncollected premium.
Supplemental documentation: File Activity Summary Sheet
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 Request for Ownership Information
Details the ownership of an entity or entities. A written signature is required.
Guidelines for Insureds that use Contractors
Provides guidance on Michigan workers’ compensation requirements for insureds that use contractors.
Sole Proprietor Independent Contractor Worksheet
To be completed if your business operates as a sole proprietor independent contractor.
Sole Proprietor Independent Contractor Supplemental Worksheet – Truckers
To be completed if you are a sole proprietor owner operator truck driver. This form supplements the separate Sole Proprietor Independent Contractor Worksheet.
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.