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Blank Michigan F 6 Form

The Michigan F 6 form is an application used to obtain workers' compensation insurance in Michigan. This form is specifically designed for employers seeking coverage through the Michigan Workers’ Compensation Placement Facility. Completing this application accurately is essential to ensure timely processing and coverage.

Outline

The Michigan F 6 form is a crucial document for businesses seeking workers' compensation insurance within the state. This application is specifically designed for employers who may find it challenging to obtain coverage through conventional means. It requires detailed information about the business, including the employer's name, legal status, and federal identification number. Additionally, the form mandates disclosure of previous insurance coverage and any relevant changes in business structure or ownership over the past five years. Employers must also outline their business operations, payroll details, and any subcontractors involved in their work. Completing this form accurately is vital, as any missing or incomplete information can lead to delays in securing coverage. It is essential to remember that coverage will not take effect until the application is received by the Michigan Workers’ Compensation Placement Facility, and payment is processed. For guidance, employers can refer to the accompanying Information and Procedures Handbook, which provides step-by-step instructions on filling out the application correctly.

Sample - Michigan F 6 Form

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.
6.	PAYROLL OFFICE ADDRESS				(STREET)		(CITY)	(STATE)	(ZIP)
	PAYROLL OFFICE ADDRESS				(STREET)		(CITY)	(STATE)	(ZIP)
6a. Total number of employees
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

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Form Information

Fact Name	Details
Form Purpose	The Michigan F 6 form is used to apply for workers’ compensation insurance through the Michigan Workers’ Compensation Placement Facility.
Governing Law	This form is governed by the Michigan Workers’ Disability Compensation Act, Public Act 317 of 1969.
Submission Requirements	The application must be typed or printed in ink. Incomplete submissions may delay coverage binding.
Effective Date	Coverage will not be bound before 12:01 AM the day after the application is received by the MWCPF.
Contact Information	The mailing address for the MWCPF is P.O. Box 3337, Livonia, MI 48151-3337. The facility can be reached at 734-462-9600.
Insurance Record	Applicants must disclose any previous workers’ compensation insurance coverage in Michigan, including details of prior policies.

Detailed Guide for Filling Out Michigan F 6

Completing the Michigan F 6 form is an essential step for employers seeking workers’ compensation insurance. This form requires careful attention to detail to ensure all necessary information is provided accurately. Following these steps will help you navigate the application process smoothly.

Gather Required Information: Collect all necessary details about your business, including the employer's name, federal identification number, contact information, and business structure.
Fill Out General Information: In the designated sections, enter the employer's name, federal employer identification number, phone number, mailing address, principal location, and payroll office address. Be sure to include the total number of employees.
Indicate Legal Status: Select the appropriate legal status of your business from the provided options, such as Sole Proprietor, Partnership, or Corporation.
Provide Insurance Record: Answer questions regarding previous workers’ compensation coverage, name changes, and any ownership interests in other businesses. Provide relevant details if applicable.
List Business Principals: Include the names, titles, duties, and approximate annual salaries of all key individuals in your organization. Indicate ownership percentages and note if any individuals are to be excluded from coverage.
Describe Nature of Business: Clearly explain the nature of your business operations. Provide details for each location and include information about any subcontractors used.
Calculate Estimated Annual Premium: Assign classification codes to each operation and calculate the total payroll and premium. Ensure you confirm payroll levels with relevant documentation.
Prepare Payment: Include the appropriate payment for the premium with your application. Acceptable payment methods include cashier’s checks or money orders made payable to the Michigan Workers’ Compensation Placement Facility.
Complete Employer’s Agreement: Read and sign the employer's agreement, certifying that all information provided is accurate and complete.
Agency and Producer Information: If applicable, fill in the agency and producer details, including their federal identification number and contact information.
Review and Submit: Before submitting, review the entire application to ensure all sections are filled out correctly. Incomplete applications may lead to delays.

After you have completed the form, it is important to submit it to the Michigan Workers’ Compensation Placement Facility promptly. Ensure that all required documents and payments are included to avoid any potential delays in processing your application.

Obtain Answers on Michigan F 6

What is the Michigan F 6 form?
The Michigan F 6 form is an application for workers’ compensation insurance specifically designed for employers in Michigan. It is managed by the Michigan Workers’ Compensation Placement Facility (MWCPF). This form is essential for businesses that need to secure workers’ compensation coverage, especially if they cannot obtain it through traditional means.
How do I obtain the Michigan F 6 form?
The form can be obtained directly from the Michigan Workers’ Compensation Placement Facility or downloaded from their website at www.caom.com. It is crucial to ensure you are using the most current version of the form to avoid any issues.
What information is required to complete the form?
To complete the Michigan F 6 form, you will need to provide various details, including:
- Employer’s name and contact information
- Federal Employer Identification Number (FEIN)
- Business structure (e.g., corporation, LLC, sole proprietorship)
- Details about previous workers’ compensation coverage
- Information about business principals and their duties
- Nature of the business and payroll details
What happens if I do not complete the form correctly?
Incomplete or incorrect information can lead to delays in binding coverage. It is essential to ensure that all sections of the form are filled out accurately. If there are any missing details, MWCPF may not be able to process your application promptly.
When does coverage become effective?
Coverage will not be bound until 12:01 AM the day following the receipt of the completed application by MWCPF. Therefore, timely submission of the form is critical to avoid any gaps in coverage.
What if my business has locations outside of Michigan?
If your business operates in states other than Michigan, you must indicate this on the form and provide details about your insurance coverage in those states. This information is crucial for the MWCPF to assess your application accurately.
Are there any penalties for providing false information?
Yes, providing false or misleading information on the application can lead to criminal prosecution. It is vital to answer all questions truthfully and completely to avoid legal repercussions.
What types of businesses are eligible for coverage?
Various types of businesses can apply for workers’ compensation insurance through the Michigan F 6 form, including corporations, partnerships, LLCs, and non-profit organizations. However, sole proprietors without employees are not eligible for benefits.
What is the process for calculating the estimated annual premium?
The estimated annual premium is calculated based on the total payroll, the classification codes assigned to each operation, and other relevant factors. It is essential to provide accurate payroll figures to ensure the premium is calculated correctly.
How do I pay the premium?
The premium must be paid via a cashier’s check, certified check, money order, agency check, or finance company check. Coverage will not be bound without the premium payment, so it is essential to include the payment with your application.

Common mistakes

Completing the Michigan F 6 form accurately is essential for obtaining workers’ compensation insurance. However, many individuals make common mistakes that can lead to delays or complications in the application process. One frequent error is providing incomplete or inaccurate contact information. This includes the employer's name, federal employer identification number, and phone number. When this information is not clearly stated, it can hinder communication and result in missed opportunities for timely coverage.

Another mistake often encountered is failing to disclose previous workers’ compensation insurance coverage. Applicants may mistakenly answer “no” to questions regarding past coverage, which can lead to complications later on. It is crucial to be honest and thorough when detailing any past insurance history, as omitting this information can delay the processing of the application and may even lead to issues with coverage eligibility.

In addition, many applicants overlook the importance of specifying the nature of their business. The form requires a detailed description of all operations at each location. A vague or incomplete explanation can lead to misclassification of the business, which may affect the premium rates and coverage terms. Providing a clear and comprehensive overview of business activities helps ensure that the application reflects the true nature of the operations.

Lastly, individuals often neglect to include necessary supporting documents, such as the exclusion form for any eligible persons. If the application does not include these documents, it can result in delays or denials of coverage. Ensuring that all required forms and attachments are completed and submitted alongside the application is vital for a smooth process. Attention to detail in these areas can significantly impact the success of obtaining workers’ compensation insurance.

Documents used along the form

When applying for workers’ compensation insurance in Michigan, several other forms and documents may be required alongside the Michigan F 6 form. These documents help provide a clearer picture of the business and its insurance needs. Below is a list of common forms that are often used in conjunction with the Michigan F 6 form.

ERM Form: This form is used to provide additional information about the business, especially in cases of name changes, ownership interests, or if the business was purchased. It helps clarify the business's history and structure.
Bankruptcy Order: If the employer is in bankruptcy, a copy of the bankruptcy order must be attached. This document outlines the legal status of the business and any implications for insurance coverage.
Exclusion Form: This form is necessary if any eligible persons are to be excluded from coverage. It details the reasons for exclusion and must accompany the application.
Payroll Records: Employers must maintain complete payroll records. These records support the estimated annual premium calculation and should be available for review by the insurance company.
Client List for Leased Employees: If the business uses employee leasing firms, a list of clients and job descriptions for each must be provided. This helps the insurer understand the nature of the workforce.
Subcontractor Information: Documentation about subcontractors is required, including statements confirming their independent contractor status. This ensures compliance with workers’ compensation laws.
Certificate of Insurance: If subcontractors are used, a valid certificate of workers’ compensation insurance must be provided to confirm their coverage.
Financial Documentation: This may include tax forms like the Social Security Form 941 or Schedule C, which help verify payroll levels and business income.
Payment Agreement: If the premium is financed, a signed copy of the financing agreement must be submitted. This outlines the terms of premium payment.
Business Description: A detailed description of the nature of the business operations is essential. This information is used to classify the business for insurance purposes.

These documents play a crucial role in ensuring that the application process for workers’ compensation insurance is smooth and complete. Properly preparing these forms can help avoid delays and ensure adequate coverage for the business.

Similar forms

The Michigan F 6 form serves as an application for workers’ compensation insurance. Several other documents share similarities with this form, primarily in their purpose and structure. Below is a list of eight documents that are comparable to the Michigan F 6 form:

Workers' Compensation Insurance Application (General): Similar in purpose, this document collects essential information from employers seeking workers' compensation coverage, including business details and employee information.
Employer's Liability Insurance Application: This form is used to apply for liability insurance that covers employers against claims from employees, mirroring the F 6 form's focus on employer responsibilities and coverage needs.
State-Specific Workers' Compensation Forms: Many states have their own versions of workers’ compensation application forms, which require similar information regarding business operations and employee counts.
Insurance Policy Renewal Application: This document is used when renewing existing workers' compensation policies, requesting updated business and employee information akin to the F 6 form.
Business Owner’s Policy Application: This application encompasses various types of insurance, including workers’ compensation, and requires details about the business structure and operations, similar to the F 6 form.
Self-Insurance Application for Workers' Compensation: Businesses seeking to self-insure must provide comprehensive details about their operations and financial status, paralleling the information required in the F 6 form.
Employee Leasing Company Application: This document is used by companies that lease employees, requiring information about the leased workforce and business operations, much like the F 6 form.
Subcontractor Qualification Form: This form collects information about subcontractors and their insurance status, similar to the F 6 form's inquiries about subcontractor relationships and insurance coverage.

Dos and Don'ts

When filling out the Michigan F 6 form for workers’ compensation insurance, it is essential to follow specific guidelines to ensure a smooth application process. Here’s a list of things you should and shouldn’t do:

Do type or print the application legibly in ink. This ensures that all information is clear and easy to read.
Don’t leave any sections blank. Missing or incomplete information can delay the binding of coverage.
Do provide accurate contact information, including your phone number and mailing address. This helps facilitate communication with the Michigan Workers’ Compensation Placement Facility.
Don’t forget to include your federal employer identification number. This number is crucial for processing your application.
Do review the Information and Procedures Handbook before submitting your application. This handbook contains important instructions that can guide you through the process.
Don’t submit your application without enclosing the required payment. Coverage will not be bound without a cashier’s check, certified check, money order, or other approved forms of payment.

By adhering to these guidelines, you can help ensure that your application for workers’ compensation insurance is processed efficiently and effectively.

Misconceptions

Misconception 1: The F 6 form is only for large businesses.

This form is applicable to all businesses, regardless of size. Even small businesses and sole proprietors must complete it if they seek workers' compensation insurance.

Misconception 2: Sole proprietors do not need to fill out the F 6 form.

Sole proprietors must still complete the form. While they may not be eligible for workers' compensation benefits, the application is necessary for any business operations.

Misconception 3: Coverage is effective immediately upon submission of the form.

Coverage does not begin until 12:01 AM the day after the Michigan Workers’ Compensation Placement Facility receives the completed application.

Misconception 4: Missing information on the form will not affect the application.

Incomplete or missing information can delay the binding of coverage. It is crucial to provide all required details accurately.

Misconception 5: Previous insurance coverage history is not important.

Applicants must disclose their previous workers’ compensation insurance coverage history. This information is vital for determining eligibility and premiums.

Misconception 6: The F 6 form does not require a premium payment.

A premium payment is necessary to bind coverage. The application will not be processed without an enclosed payment.

Misconception 7: The F 6 form is only for Michigan-based businesses.

While the form is specifically for Michigan, businesses with operations in other states must also report this information on the form.

Key takeaways

Key Takeaways for the Michigan F 6 Form

Complete the form accurately and legibly, using either typed text or ink. Incomplete or incorrect information can delay coverage.
Submit the application along with the required premium payment. Coverage will not be effective until the payment is received.
Be aware that coverage will not begin until 12:01 AM the day after the Michigan Workers’ Compensation Placement Facility receives the application.
Ensure all required documents, such as previous insurance records and exclusion forms, are included to avoid processing delays.