ACORD 811 (2005/01)

Section Name
Field Name
Field and/or Section Description
ACORD 171 MI (2005/01)
Michigan Application for Exclusion
of Executive Officers of a
Corporation or Members/Managers
of a Limited Liability Company
Use this form to notify the workers compensation insurance company that certain
executive officers of a corporation or members/managers of a limited liability company
elect to be excluded from workers compensation insurance coverage.
ACORD 811 (2005/01)
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