The Michigan F 6 form is a detailed application for businesses seeking workers' compensation insurance through the Michigan Workers' Compensation Placement Facility. It outlines the requirements for applying, such as providing business and insurance records, information about the nature of the business, and estimated premium calculations. To ensure your business is protected and compliant with state laws, click the button below to fill out the Michigan F 6 form promptly.
In navigating the complexities of securing workers' compensation insurance within Michigan, the Michigan F 6 form emerges as a foundational document designed to streamline the application process for employers. Situated at the heart of the Michigan Workers’ Compensation Placement Facility's efforts to facilitate coverage, this form serves as a conduit for businesses seeking to fulfill their legal obligations towards their employees. The process outlined in the form encapsulates a broad spectrum of information gathering, from basic employer identification details to the intricate dynamics of insurance history and business operations. Employers are required to meticulously provide data on their legal status, payroll details, and the nature of their business operations, ensuring a comprehensive overview that aids in the precise computation of premiums. Particularly emphasized are the provisions for businesses that might possess operations in other states or those engaging in subcontracting, which necessitates additional declarations. Furthermore, the document places a strong onus on adherence to state laws and regulations concerning employee welfare, health, and safety, underlining the insurance's role as not just a financial safeguard but also a commitment to fostering a safe working environment. Through the candid disclosure of information, coupled with a commitment to regulatory compliance, the form encapsulates the state’s endeavor to promote a culture of responsibility and protection in the workplace.
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
5.
OTHER MICHIGAN LOCATIONS
6.
PAYROLL OFFICE ADDRESS
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.
POLICY NUMBER
POLICY PERIOD
PREMIUM
F-6 (1-04) page 1 of 5
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. _________________________________________________________________________________
Was this an existing business purchased by the insured?
Yes; If yes, give previous name, date of purchase and
Do owner(s) own a majority interest in any other business?
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
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
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
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
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:
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
* Signature (Corporate Officer, General Partner
Type or Print
*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
Filling out the Michigan F 6 form is a crucial step in ensuring your business is compliant with state workers' compensation insurance requirements. The process may seem complex at first, but breaking it down into steps can make it much easier to navigate. Before diving into the paperwork, gather all necessary information, including your business details, federal employer identification number, details about your operation, and any previous insurance records. This will streamline the process, allowing for a smooth, accurate completion and submission of your application.
Once the form and all necessary documents are prepared, submit everything to the Michigan Workers’ Compensation Placement Facility via mail or express delivery service to the addresses provided. Remember, coverage will only begin after the Facility has received and processed your completed application, so it's essential to confirm that every section is thoroughly and accurately filled out. This attention to detail will help avoid any delays or issues with binding your coverage.
The Michigan F 6 form is a comprehensive document designed specifically for businesses applying for workers' compensation insurance through the Michigan Workers’ Compensation Placement Facility. This form facilitates the administrative process for businesses that are either starting new, transitioning, or are unable to secure workers' compensation insurance through customary market channels. It collects detailed information about the business, including general information, insurance record, details about the nature of the business and premium computation, and requires an agreement from the employer regarding the maintenance of records and compliance with safety laws.
Any business operating in Michigan that seeks to obtain workers' compensation insurance through the Michigan Workers’ Compensation Placement Facility (MWCPF) needs to complete the F 6 form. This typically includes businesses that are new, have a lapsed coverage history, or are unable to procure insurance through the private market due to various reasons. Specifically, sole proprietors, partnerships, corporations, non-profits, LLCs, LLPs, trusts, or any other legal form of business entities applying for workers’ compensation coverage are required to fill out this form. However, it's important to note that sole proprietors are not eligible for workers' compensation benefits under certain conditions outlined in the form.
Additionally, the employer's agreement section mandates adherence to laws and regulations regarding employee welfare, health, and safety, and acceptance of the insurance procedures and conditions set forth by the MWCPF.
The Michigan F 6 form can be submitted either via mail or express delivery. For mailing, the form should be sent to P.O. Box 3337, Livonia, MI 48151-3337. For express mail or if delivering in person, the address is 17197 N. Laurel Park Dr., Suite 311, Livonia, MI 48152-2686. It's critical that the form is typed or legibly printed in ink to avoid processing delays. Coverage will not be bound sooner than 12:01 AM the day following the receipt by the MWCPF. Thus, ensuring that the form is complete and devoid of missing information is crucial for timely processing.
Filling out the Michigan F-6 form, an application for Workers' Compensation Insurance, is a critical process for employers. Yet, many people make mistakes during this process. Understanding these common errors can help ensure that the application is completed correctly, thereby facilitating the timely binding of coverage.
1. Not following instructions: A frequent mistake is not reviewing or adhering to the guidance provided in the Michigan Workers' Compensation Placement Facility’s Information and Procedures Handbook. This resource is key to understanding the detailed requirements and avoids common pitfalls in the application process.
2. Incomplete or illegible information: Applicants often submit forms with missing details or handwriting that's difficult to read. Since the application must be typed or legibly printed in ink, ensuring clarity and completeness is essential to avoid delays in the binding of coverage.
To navigate these challenges effectively, applicants should thoroughly review the form instructions, double-check all entered information for accuracy, and consult the handbook or a professional if uncertainties arise. By addressing these common mistakes, employers can facilitate a smoother application process for Michigan Workers' Compensation Insurance.
When submitting the Michigan F-6 form, an Application for Workers’ Compensation Insurance, certain additional forms and documents are often required to ensure the application is thorough and adheres to the necessary legal and regulatory standards. These supplemental documents play crucial roles in establishing the business's eligibility, understanding its operations, and ensuring compliance with the state's workers' compensation laws. Here's a look at some of these essential forms and documents that often accompany the Michigan F-6 form submission.
Gathering these documents in conjunction with completing the Michigan F-6 form is crucial for smooth processing and to ensure the business obtains the necessary workers’ compensation coverage efficiently. Proper documentation supports the business's application and helps represent its operations, financial stability, and commitment to safety accurately, which are key factors in securing favorable insurance terms.
The Michigan F 6 form is similar to other documents used across the United States for workers' compensation insurance applications. These forms are pivotal for businesses to obtain the necessary insurance to cover their employees in case of workplace injuries. While there are variations in each state's specific requirements and form layouts, the core intention remains consistent: to gather comprehensive information about the employer, their business, and their insurance needs to facilitate the provision of workers' compensation coverage.
The Acord 130 Workers Compensation Application is one such document that shares a lot of similarities with the Michigan F 6 form. Both forms aim to collect detailed information about the employer's business, including general information, insurance history, and specifics about the nature of the business operations. They ask for employer identification numbers, detailed descriptions of the business activities, and information about previous and current workers' compensation insurance policies. These forms serve as the basis for calculating the premium and determining the eligibility and terms of the workers' compensation insurance coverage.
Another comparable document is the Employer's Report of Change (Form DWC 020) used in states like California. Though primarily intended for reporting changes in an employer's status or business, it requires similar detailed business information to what the Michigan F 6 form collects. This includes changes in the legal structure, business location, and insurance coverage. By providing updates about the employer's business and insurance, the DWC 020 helps maintain accurate records for workers' compensation purposes, paralleling the Michigan F 6 form's goal of ensuring up-to-date and accurate information is on file for each insured entity.
Filling out the Michigan F-6 form, a crucial step in securing workers’ compensation insurance, requires careful attention to detail and thoroughness. To help navigate this process smoothly, here is a list of essential dos and don'ts.
Do:
Don’t:
By following these guidelines, you will be better prepared to complete the Michigan F-6 form accurately and efficiently, facilitating a smoother process in securing workers’ compensation insurance for your business.
Understanding the Michigan F6 form and navigating through the misconceptions surrounding it is crucial for employers seeking workers' compensation insurance. Here are ten common misunderstandings cleared up to provide clarity:
Dispelling these misconceptions enhances understanding and streamlines the application process, ensuring employers meet all requirements for obtaining workers' compensation insurance in Michigan effectively.
Filling out and using the Michigan F 6 form for Workers' Compensation Insurance comes with its set of requirements and involves paying attention to several critical points. Here are six key takeaways to ensure you navigate this process effectively:
Adhering to these key takeaways when completing the Michigan F 6 form can streamline the process of securing workers’ compensation insurance, ensuring that both employers and employees are duly protected in accordance with state regulations.
Michigan Sales Tax Exemption Rules - Companies must also report any affiliations with Michigan entities that may refer customers to them, potentially affecting their tax nexus.
Michigan Self Employment Tax Calculator - The calculation involves converting fringe benefits included in Box 14 of the T-4, not taxable in the U.S.