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Copy of current policy declaration page – Showing Class Codes and Payroll
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5 Year Loss Runs (Please sign attached Loss Run Request – Please photo-copy onto your store\Company Letterhead)
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Signed NCCI Experience Modification Sheet (attached – Please photo-copy onto your store\Company Letterhead)
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Owners/Officer Worksheet (attached)
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Your business FEIN for entity to be covered and reported for proof of coverage.
Please contact either Sean McCutcheon or Kevin McCutcheon for a MFDA Workers Compensation Proposal:
Sean McCutcheon
(406) 457-2136
Kevin McCutcheon
(406) 457-2111
Or contact
McKee Anderson MFDA President for any questions
1-800-735-1082