State Land Bank Authority

State of Michigan

Official Website: https://www.michigan.gov/leo/bureaus-agencies/landbank

Forms & Documents

Browse all State Land Bank Authority government forms

21 - 36 of 36 forms

Form Title Topics
MULTIPLE CARRIER REDEMPTION FORM
NOTICE OF TERMINATION OF LIABILITY
PROVIDER’S REPORT OF CLAIM & REQUEST FOR MEDICAL PAYMENT
PROVIDER'S REQUEST FOR RECONSIDERATION
REQUEST FOR COMPLIANCE HEARING
SELF-INSURED GROUP NOTICE OF ACCEPTANCE OF MEMBERSHIP
SELF-INSURER REQUEST TO ADD OR DELETE SUBSIDIARY/AFFILIATE
SELF-INSURER REQUEST TO ADD OR DELETE SUBSIDIARY/AFFILIATE
SELF-INSURER’S CLAIMS TRANSFER AGREEMENT
WC-402 - Self-Insurer Application Packet (fill-in form)
WC-500 - VR Provider Professional Disclosure Statement
WC-701 Filing Instructions
WORKERS’ COMPENSATION AGENCY SERVICE COMPANY APPLICATION
WORKERS DISABILITY COMPENSATION GROUP SELF-INSURER APPLICATION
WORKER’S SETTLEMENT STATEMENT
WORK HISTORY, WORK QUALIFICATIONS & TRAINING DISCLOSURE QUESTIONNAIRE

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