Michigan Restaurant Association

Self -Insured Workers Comp Fund - Information Request

First Name *

Last Name *

Email *

Restaurant Name:

Address:

Address 2:

City: *

State: *

Zip:

County

Phone: *

Fax:

Best time to contact:

Current Carrier: *

Expiration Date of Current Policy:

Total Annual Payroll: *

Current Annual Premium: *

How did you hear of this program? *

Comments:

Please enter the text from the image above: