MECC: Midwest Employers Casualty Company

Forms & Applications

Group Self-Insurance Application for Excess Workers Compensation Coverage

Group Self-Insurance Renewal Application for Excess Workers’ Compensation Coverage

Large Deductible WC Application

Large Deductible WC Renewal Application

Large Deductible Risk Concentration Form

Specific Excess Policy Form

Aggregate Excess Policy Form

Specific/Aggregate Excess Policy Form

State-Specific Applications

Nevada Individual Self-Insurance Application for Excess Workers’ Compensation Coverage

Nevada Individual Self-Insurance Renewal Application for Excess Workers’ Compensation Coverage

Nevada Group Self-Insurance Application for Excess Workers’ Compensation Coverage

Nevada Group Self-Insurance Renewal Application for Excess Workers’ Compensation Coverage

Washington Individual Self-Insurance Application for Excess Workers’ Compensation Coverage

Washington Individual Self-Insurance Renewal Application for Excess Workers’ Compensation Coverage

Other

Exhibit I-4 - Aircraft Supplemental Application

Aircraft Supplement Application - Detail Table

Aircraft- Florida Supplemental Application

Individual Self-Insurance Concentration of Risk

Group Self-Insurance Concentration of Risk

Fraud Warning Supplement

MECC Employer Profile Questionnaire – Claims

MECC Employer Profile Questionnaire – Loss Prevention

Healthcare Supplemental Application

Exhibit I-6 - Vehicle Supplemental Application

Individual and Group Pilot Application for Excess Workers' Compensation

Nanotechnology Supplemental Questionnaire

Claims Administration Forms and Questionnaires

First Notice of Loss

First Notice of Loss - Reinsurance

Reporting Requirements

Large Deductible Reporting Requirements

Reinsurance Reporting Requirements

Reinsurance Claim Administration Questionnaire

Self-Administration Questionnaire

Service Company Questionnaire

Aggregate Reimbursement Request

Specific Reimbursement Request

Large Deductible Replenishment Request

Reinsurance Reimbursement Request

Service Company Verification Form

Staff Review