Free Self-Insurance Application Checklist - Michigan

Application for Self-Insurance Checklist
Completed Application Statement of Financial Status Prepared in accordance with generally accepted accounting principles, covering a oneyear period ending not more than twelve (12) months before the date of application, and audited by a certified public accountant. Excess Insurance A copy of the declaration sheet of any excess insurance policy intended as partial security. Written Estimate of Loss Reserve Either of the following: · Prepared by a qualified actuary. · Prepared in conformity with the loss reserve methodology approved for utilization by a qualified actuary within the two-year period immediately preceding the date of original application and certified by an owner, officer or director. · Prepared by a casualty insurance company. Claim Contact Copy of written authorization designating a specific person to receive and process claims. Sample Claim Form A copy of a claim form to be used to submit a claim for benefits. The claim form shall include all the following information: · A statement of claimant's right to personal protection insurance benefits, property protection insurance benefits, and residual liability insurance benefits under the nofault law. · A statement of a self-insurer's responsibility to pay claims in a timely manner. · An instruction that directs claimants to contact the Secretary of State concerning a self-insurer's failure to fulfill its responsibilities under the no-fault law. Motor Vehicles Registered in Michigan A list of all motor vehicles that are registered in Michigan in the name of the applicant at the time of application or that are to be self-insured under a certificate of self-insurance issued to the applicant. The vehicles shall be identified by all of the following: · Year · Make · Model · Vehicle Identification Number (VIN) · License Plate Number

Send completed application package to: Assigned Claims Facility 7064 Crowner Drive Lansing, MI 48918 (517) 322-1875