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Documents used along the form

The Michigan F 6 form is essential for applying for workers' compensation insurance in Michigan. Alongside this form, several other documents often accompany the application process. Each of these forms serves a specific purpose and helps ensure a smooth application experience.

  • ERM Form: This form is required when there are changes in business name, ownership, or if the business is being purchased. It provides necessary details to update the insurance records accurately.
  • Bankruptcy Order: If the employer is in bankruptcy, a copy of the bankruptcy order must be attached. This document informs the insurance company of the financial status of the employer.
  • Georgia WC-3 Form: This essential document is used to formally dispute a worker's compensation claim and notifies the State Board of Workers' Compensation of the challenge. Understanding its importance can significantly influence the claims process. For more information, visit Forms Georgia.
  • Subcontractor Statement: This statement verifies the status of subcontractors used by the employer. It outlines the criteria for determining independent contractor status and ensures compliance with workers' compensation laws.
  • Premium Payment Check: A cashier’s check or certified check for the premium payment must accompany the application. This document is crucial for binding the coverage as it confirms the financial commitment.
  • Exclusion Form: If any eligible individuals are excluded from coverage, this form must be completed and submitted. It details the reasons for exclusion and maintains transparency in the application.

These documents play a vital role in the workers' compensation application process. Ensuring all necessary forms are completed and submitted can expedite the binding of coverage and prevent delays.

Michigan F 6 Preview

MICHIGAN APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

MICHIGAN WORKERS’ COMPENSATION PLACEMENT FACILITY

MAIL: P.O. Box 3337, Livonia, MI 48151-3337

EXPRESS MAIL AND VISITORS: 17197 N. Laurel Park Dr., Suite 311, Livonia, MI 48152-2686

734-462-9600

IMPORTANT: Instructions for completing this application can be found in the Michigan Workers’ Compensation Placement Facility’s Information and Procedures Handbook. This handbook is available from the Michigan Worker’s Compensation Placement Facility or at www.caom.com.

This application must be typed or legibly printed in ink. Under no circumstance will coverage be bound sooner than 12:01 AM the day following receipt by MWCPF. Missing or incomplete information may delay the binding of coverage.

I. GENERAL INFORMATION

 

 

EFFECTIVE 12:01 AM (DATE)

 

 

 

 

 

 

 

 

 

(To be completed by the Facility) _________________

1.

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF EMPLOYER

 

 

 

 

 

 

 

2. _____-________________________________

 

__(________)_______________________

 

 

FEDERAL EMPLOYERS IDENTIFICATION NUMBER

 

PHONE NUMBER

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS

 

(STREET)

(CITY)

(STATE)

(ZIP)

4.

 

 

 

 

 

 

 

 

 

 

 

 

PRINCIPAL LOCATION

 

(STREET)

(CITY)

(STATE)

(ZIP)

5.

 

 

 

 

 

 

 

 

 

 

 

OTHER MICHIGAN LOCATIONS

(STREET)

(CITY)

(STATE)

(ZIP)

6.

 

 

 

 

 

 

 

 

 

 

PAYROLL OFFICE ADDRESS

(STREET)

(CITY)

(STATE)

(ZIP)

 

6a. Total number of employees

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

 

LEGAL STATUS

__ Sole Proprietor* __ Partnership

__ Corporation

__ Non-Profit Corp __ Limited Partnership

 

 

 

 

__ LLC

 

__ LLP

__ Trust

__ Other (explain) _____________________

*A sole proprietor is not eligible for workers’ compensation benefits

*A sole proprietor with no employees working for a distinct entity is an employee of that entity. Supply a list of entities for which work is performed.

8. Are there operations in states other than Michigan?

__ No __ Yes;

If yes complete the following

 

 

 

 

 

(If uninsured indicate under Insurance Carrier)

 

 

 

STATE

LOCATION

INSURANCE CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II. INSURANCE RECORD

 

 

 

 

 

 

 

1. Has there been previous workers’ compensation insurance coverage in Michigan?

 

 

 

__

No; If no, complete

__ New business

__ Self Insured

__ Other (explain) ____________________________

__

Yes;

If yes, provide insurance record – three previous years

 

 

 

 

 

 

 

If previously self-insured, give name of self-insured employer or group fund if different from the above named insured.

 

STATE

INSURANCE CARRIER

POLICY NUMBER

POLICY PERIOD

PREMIUM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F-6 (1-04) page 1 of 5

MICHIGAN APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

II. INSURANCE RECORD (CONTINUED)

2.

Has there been a name change during the past five years?

__

No

__

Yes; If yes, give previous name and date of change and

 

complete an ERM form. _________________________________________________________________________________

3.

Was this an existing business purchased by the insured?

__

No

__

Yes; If yes, give previous name, date of purchase and

 

complete an ERM form. _________________________________________________________________________________

4.

Do owner(s) own a majority interest in any other business?

__

No

__

Yes; If yes, give the complete legal name of the other

 

entity(s) and complete an ERM form. _______________________________________________________________________

5.Do you (applicant) have a workers’ compensation insurance policy in force?

__ No __ Yes; If yes, indicate expiration or cancellation date: _________________________________________

6.Are you in debt to any insurance company for any unpaid premium for worker’s compensation?

__ No __ Yes; If yes, explain: ___________________________________________________________________

7. Is the employer in bankruptcy? __ No

__ Yes; If yes, attach a copy of the bankruptcy order.

III.BUSINESS PRINCIPALS

1.List below the name and title of all officers, general partners, members of limited liability company or spouse of sole proprietor. Indicate duties and approximate annual salaries for each person. If eligible persons are to be excluded check the space below. The appropriate completed exclusion form must accompany this application. (See information and Procedures handbook for exclusion eligibility.)

2.Indicate percentage of ownership for each person listed. If 100% of ownership is not shown, complete and submit an ERM form with this application.

 

 

 

 

 

PERCENTAGE

 

APPROXIMATE

NAME

TITLE

EXCLUDE

OWNED

DUTIES

ANNUAL SALARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. If eligible persons are excluded, is the appropriate exclusion form attached? __ No __ Yes

If not excluded, have payrolls for officers, partners, LLC members or spouse been included in determining the estimated annual premium? __ No __ Yes

IV. NATURE OF BUSINESS AND PREMIUM COMPUTATION

1.Explain nature of business. Completely describe all operations at each location. (Do not use manual phraseology for description.) If more than one legal entity is to be insured indicate each named entity’s operation.

2.If you use subcontractors in your business, ask your agent to tell you about the rules for audits for money paid to the subcontractors. The employee/employer relationship will be governed by the elements of rule Nine F part 3 and part 5 in the Facility Basic Manual and the Information and Procedures Handbook.

F-6 (1-04) page 2 of 5

MICHIGAN APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

IV. NATURE OF BUSINESS AND PREMIUM COMPUTATION (CONTINUED)

3. Are employees leased? __ No __ Yes If yes, provide name and address of leasing company. ________________________

4.Employee leasing firms and temporary contractors must furnish a client list. Include a brief job description for each client.

5.Calculation of Estimated Annual Premium: Assign a classification code to each individual operation. (Attach additional sheet if necessary.) IF PAYROLL LEVELS DIFFER FROM THE MOST RECENT AUDIT OR PREVIOUS POLICY, CONFIRM APPLICATION PAYROLL LEVELS WITH SOCIAL SECURITY FORM 941, TAX FORM SCHEDULE C (BOTH SIDES), CURRENT PAYROLL SCHEDULE, OR M.E.S.C. REPORT.

TOTAL PAYROLL BASIS

Describe by location the duties

Class

Number of

Total

 

 

of employees

Code

Employees

Payroll

Rate

Premium

 

 

 

 

 

 

 

 

Total Premium

 

 

Experience Modification

 

 

Standard Premium

 

 

Less Premium Discount

 

 

Expense Constant

DEPOSIT PREMIUM

 

Rate Plan _____ Surcharge

1. DEPOSIT REQUIRED:

Terrorism Premium (total payroll/100 x .01)

Under $1,000

100%

Total Estimated Annual Premium

 

 

Percentage of annual estimated premium to

$1,000 to $2,500

50%

determine Deposit Premium

Over $2,500

25%

Deposit Premium

The balance of the Total Estimated Annual Premium is to be paid according to a deferred payment plan established by the servicing carrier.

2.PREMIUM PAYMENT

Enclose CASHIER’S CHECK, CERTIFIED CHECK, MONEY ORDER, AGENCY CHECK OR FINANCE COMPANY CHECK for premium payment. Coverage will not be bound without one of the above.

ENCLOSED IS CHECK NUMBER _______________________ MADE PAYABLE TO THE MICHIGAN WORKERS’ COMPENSATION

PLACEMENT FACILITY (MWCPF) IN THE AMOUNT OF $ __________________.

Is the premium Financed? __ No __ Yes; If yes, attach a signed copy of the agreement.

F-6 (1-04) page 3 of 5

MICHIGAN APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

VI. EMPLOYER’S AGREEMENT

The employer must:

1.Maintain a complete record of all payroll transactions in such form as the insurance company may reasonably require. Such record will be available to the company at the designated address.

2.Comply substantially with all laws, orders, rules and regulations in force and effect made by the public authorities relating to the welfare, health and safety of employees.

3.Comply with all reasonable recommendations made by the insurance company relating to the welfare, health and safety of employees.

The undersigned employer certifies that:

1.The employer has read and understands the application and has truthfully answered all questions.

2.The undersigned employer hereby applies for assigned risk workers’ compensation insurance in Michigan and expressly represents that such insurance is being sought in good faith and that the employer is making such application with knowledge that the employer is unable to procure workers’ compensation insurance through ordinary methods.

3.The employer understands that by making application to the Michigan Workers’ Compensation Placement Facility, his Business Name, City, Risk I.D. Number, Premium, Expiration Date, Class Code, Experience Modification, and any Assigned Risk Surcharge will be published quarterly in the Michigan Workers’ Compensation Placement Facility Depopulation Report, issued to any interested party, in an effort to depopulate the Assigned Risk Plan.

4.Any person who knowingly provides false or misleading information on this application for workers’ compensation insurance may be subject to criminal prosecution.

___________________________________________________________________________________________________________

Print or type Employer Name and Title

Date

* Signature (Corporate Officer, General Partner)

 

 

(Individual Proprietor, Member or Manager of LLC)

*If a person other than those listed has signed this application attach a copy of the power of attorney or other legal document assigning authority for signature.

VII. NON-STATUTORY COVERAGE

The Facility provides federal coverage as an adjunct to State Act Coverage. If you have admiralty (Jones Act) exposure and insure such in a Facility policy, the fact that you also have a Protection and Indemnity policy on vessels does not negate the Facility coverage and premium is due.

VIII. AGENCY AND PRODUCER

___________________________________________

AGENCY FEDERAL IDENTIFICATION NUMBER

Agency ___________________________________________________________________________(______)_______________

NamePhone Number

Address ___________________________________________________________________________(______)_______________

StreetCityState Zip Fax Number

Producer _________________________________________________________________________________________________

Name (Print or Type)

Signature

Date

Agency contact person

 

 

 

(if other than producer)

_____________________________________

E-Mail __________________________________

NOTE:

IF THE APPLICATION IS NOT COMPLETELY FILLED OUT AN EFFECTIVE DATE WILL NOT BE GIVEN

F-6 (1-04) page 4 of 5

MICHIGAN APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

SUBCONTRACTOR STATEMENT

Criteria used to determine subcontractor status vary from situation to situation. Refer to Rule IX. F. SUBCONTRACTORS in the Basic Manual for Workers’ Compensation and Employers Liability Insurance (1997 Edition). At a minimum (additional information may be required), the following information must be supplied at audit on each subcontractor who is a sole proprietor with no employees (claiming to be an independent contractor) you use during the course of a given policy period:

1.A written statement that the sole proprietor has no one working for him/her.

2.A copy of printed business material (advertisement, certificate of general liability insurance, filed dba or assumed name document, business card, etc.) used by the subcontractor in the operation of his/her business.

3.A list of other entities the sole proprietor has worked for in the past 6 months.

In the case of over-the-road, long-haul truck drivers, subcontractors who are sole proprietors must provide:

1.A written statement that the sole proprietor has no one working for him/her.

2.A written statement that the sole proprietor owns his/her own vehicle (tractor and/or trailer).

In all cases where the subcontractor is a sole proprietor with employees, a partnership, corporation, LLC or other entity, a valid certificate of workers compensation insurance or a properly filed BWC 337 (if the entity is qualified) form must be provided. Failure to provide this information on subcontractors will result in additional premium being charged at audit.

IT MUST BE UNDERSTOOD BY INDIVIDUALS USING THIS DOCUMENT TO DECLARE THEIR INDEPENDENT CONTRACTOR STATUS: THEY ARE NOT ELIGIBLE FOR WORKERS COMPENSATION BENEFITS PROVIDED BY POLICIES WRITTEN TO PROTECT ENTITIES THEY WORK FOR. ALSO, MEETING THE REQUIREMENTS OF THIS DOCUMENT IS NOT AN ATTEMPT TO EVADE THE WORKERS’ COMPENSATION LAWS OF THE STATE OF MICHIGAN, NOR IS IT GIVING UP THE RIGHT TO WORKERS COMPENSATION COVERAGE; IT IS A STATEMENT OF FACT IN SUPPORT OF DECLARING INDEPENDENT CONTRACTOR STATUS IN CONJUNCTION WITH SECTION 418.161(N) OF THE STATE OF MICHIGAN, WORKERS’ DISABILITY COMPENSATION ACT, PUBLIC ACT 317 OF 1969.

Employer Name and Title

Date

* Signature (Corporate Officer, General Partner

Type or Print

 

(Individual Proprietor, Member or Manager of LLC)

*If a person other than those listed has signed this application, attach a copy of the power of attorney or other legal document assigning authority for signature.

THIS SUBCONTRACTOR STATEMENT IS PART OF THE APPLICATION AND MUST BE SIGNED AND SUBMITTED WITH THE APPLICATION.

06-06

Revised 06-06

F-6 (1-04) page 5 of 5

Similar forms

  • Workers’ Compensation Policy Application: Similar to the Michigan F 6 form, this document serves as an official request for workers' compensation insurance. It requires detailed information about the employer, including business operations, payroll, and prior insurance history, ensuring that the insurance provider has sufficient information to assess risk and determine coverage.
  • Employer's Liability Insurance Application: This application is closely related as it seeks coverage for legal liabilities that may arise from employee injuries not covered under workers' compensation. Both documents require information about the business, its employees, and any previous claims, emphasizing the importance of understanding the employer's risk profile.
  • Affidavit of Gift Form: To document the voluntary transfer of assets, utilize the essential Affidavit of Gift form resources to ensure all legal requirements are met.
  • Certificate of Insurance: While this document serves as proof of insurance coverage, it is often generated following the completion of applications like the F 6. It contains essential details such as policy numbers and coverage limits, similar to the information an employer must provide in the application process.
  • Business License Application: This document is necessary for operating legally within a jurisdiction and often requires similar information about the business structure, ownership, and location. Just as the F 6 form collects data to assess eligibility for workers' compensation, a business license application evaluates compliance with local regulations.
  • Payroll Records: Though not an application, payroll records are crucial for determining workers' compensation premiums and coverage. They provide insight into employee numbers and wages, paralleling the F 6 form's request for payroll details to calculate the estimated annual premium.

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Misconceptions

Misconceptions about the Michigan F 6 form can lead to confusion for employers seeking workers’ compensation insurance. Here are seven common misconceptions, along with clarifications:

  • Only large businesses need to fill out the F 6 form. Many small businesses, including sole proprietors, must complete this form if they require workers' compensation insurance.
  • The F 6 form guarantees immediate coverage. Coverage cannot be bound until the application is received by the Michigan Workers’ Compensation Placement Facility, and it takes effect at 12:01 AM the following day.
  • All employees are automatically covered under workers’ compensation. Sole proprietors without employees are not eligible for coverage, which can lead to misunderstandings about their status.
  • Providing incomplete information is acceptable. Missing or incomplete details can delay the binding of coverage, making it crucial to provide all required information accurately.
  • Only the business owner needs to sign the application. The application must be signed by an authorized individual, such as a corporate officer or general partner, and may require additional documentation if signed by someone else.
  • All previous insurance records are irrelevant. The form requires a history of previous workers’ compensation insurance coverage, as it helps assess risk and determine premiums.
  • Subcontractors do not need to be reported. If subcontractors are used, their status must be clarified, and documentation may be required to avoid additional premiums during audits.

Understanding these misconceptions can help employers navigate the application process more effectively and ensure compliance with Michigan's workers' compensation regulations.

Detailed Instructions for Using Michigan F 6

Filling out the Michigan F 6 form is a necessary step for employers seeking workers' compensation insurance. Accuracy is crucial, as missing or incomplete information can delay coverage. Follow these steps to ensure your application is completed correctly.

  1. Obtain the Michigan F 6 form from the Michigan Workers’ Compensation Placement Facility or download it from their website.
  2. Type or print your information clearly in ink. Avoid using pencil.
  3. In the GENERAL INFORMATION section, fill in the effective date, employer name, Federal Employer Identification Number, and phone number.
  4. Provide the mailing address, principal location, and any other Michigan locations where business operations occur.
  5. Enter the payroll office address and total number of employees.
  6. Indicate your legal status by checking the appropriate box and providing any necessary explanations.
  7. Answer whether you have operations in states other than Michigan, and if so, provide details.
  8. In the INSURANCE RECORD section, state if you have had previous workers' compensation insurance coverage in Michigan and provide any necessary details if applicable.
  9. Indicate if there has been a name change in the past five years and provide the previous name if applicable.
  10. Answer questions regarding ownership interests in other businesses and any existing workers' compensation policies.
  11. List all business principals, including their names, titles, duties, approximate annual salaries, and ownership percentages.
  12. In the NATURE OF BUSINESS AND PREMIUM COMPUTATION section, describe your business operations thoroughly.
  13. Indicate if employees are leased and provide the leasing company's details if applicable.
  14. Calculate the estimated annual premium based on the payroll and classification codes, ensuring to attach any necessary documentation.
  15. Prepare your premium payment in the form of a cashier’s check, certified check, money order, or agency check, and note the check number and amount.
  16. Review the EMPLOYER’S AGREEMENT section, ensuring you understand and agree to the terms outlined.
  17. Print or type your name and title, sign the application, and date it.
  18. Complete the AGENCY AND PRODUCER section with the agency information and producer's details.
  19. Double-check all sections for completeness before submission.

Dos and Don'ts

When filling out the Michigan F 6 form for workers’ compensation insurance, there are important do's and don'ts to keep in mind. Following these guidelines can help ensure a smooth application process.

  • Do type or print legibly in ink. Clarity is key to avoid misunderstandings.
  • Do provide complete and accurate information. Missing details can delay your coverage.
  • Do include a cashier’s check or certified payment for the premium. Coverage won't be bound without it.
  • Do read the Michigan Workers’ Compensation Placement Facility’s Information and Procedures Handbook. It offers valuable guidance.
  • Don't leave any sections blank. Every part of the form is important for your application.
  • Don't provide false information. Misrepresentation can lead to serious consequences, including criminal prosecution.