Self-Insured Forms

In an effort to assist our clients, we have placed links here to locate specific claim documents pertaining to Self-Insured companies at the Michigan Workers’™ Compensation Agency. Clicking on a link below will cause you to navigate away from this site briefly in order to open or download the PDF form from the WCA site. To ensure the most current versions of form, you may wish to visit WCA directly. (This link will open in a new window.)

-WC-402 Self-Insurer Application Packet

-WC-402A Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form)

-WC-402G – Group Self-Insurer Application Packet

-WC-402GR – Group Self-Insurer Application (fill-in form)

-WC-404 – Service Company Application (fill-in form)

-WC-650 – Self-Insured Group Notice of Acceptance of Membership (fill-in form)

-WC-651 – Notice of Termination of Membership (fill-in form)

-Letter of Credit/Memorandum of Understanding (fill-in form)

-Michigan Continuous Surety Bond

-Michigan Certificate of Specific/Aggregate Excess Liability Insurance

-Self-Insurer’s Claims Transfer Agreement