Section 257.533. Application; form; completeness; signature; effective date; accompanying documents.

(1) A person who seeks to qualify as a self-insurer shall submit an application for a certificate of self-insurance to the secretary of state on a form provided by the secretary of state.

(2)    The application for a certificate of self-insurance shall contain complete answers to all questions and shall be signed by the person  who makes  the application   or  by  the    applicant's    duly    authorized representative.

(3)   An application shall be submitted to the secretary of state not less than 30 days before the desired effective date of the certificate.

(4)   An  application  shall  be accompanied  by all   of   the  following documents:

(a)     A statement of financial   status  which  has  been   prepared  in accordance with generally accepted accounting   practices  and   principles, which has been certified by a certified public  accountant,   and  which covers a 1-year period ending not more than 12 months before the  date   of application.

(b)   A copy of the declaration sheet of any policy of excess insurance that is intended to be used as partial security.

(c)   Either of the following:

(i)   A written estimate of loss reserve that is prepared  by  a  qualified actuary.

(ii)    A written estimate of loss reserve which is prepared in conformity with the loss reserve methodology that is approved for utilization by the self-insurer by a qualified actuary within the 2-year period immediately preceding the date of the self- insurer's original application pursuant to the provisions of these rules and which is certified by an owner, officer, or director of the self-insurer.

(iii)    A written estimate of loss reserve that is prepared by a casualty insurance company.

(d)  A copy of  a   written  authorization  that   designates  a  specified employee of the applicant, or another authorized person, to receive and process claims that are submitted to the applicant.

(e)   A copy of a claim form that shall be used by a person who submits a claim to the applicant for benefits due to suffering accidental  bodily injury or  property damage arising out of the  ownership,   operation, maintenance, or use of a motor vehicle that is registered or owned by  the applicant.

(f)  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 as determined at the time of application. The vehicles shall  be identified  by all of the following:

(i) Make.

(ii) Model.
(iii) Year.
(iv) Vehicle identification number (VIN).
(v) Registration number.
(5) A claim form that accompanies an application shall	include	all	of the

following information:

(a)   A statement of a claimant's right to personal protection insurance benefits, property protection insurance benefits, and residual  liability insurance benefits under the no-fault law.

(b)    A statement of a self-insurer's responsibility to pay claims in  a timely manner.

(c)    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.

History: 1993 AACS.