1. Copy of current policy declaration page – Showing Class Codes and Payroll

  2. 5 Year Loss Runs (Please sign attached Loss Run Request – Please photo-copy onto your store\Company Letterhead)

  3. Signed NCCI Experience Modification Sheet (attached – Please photo-copy onto your store\Company Letterhead)

  4. Owners/Officer Worksheet (attached)

  5. 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

Smccutcheon@paynewest.com

(406) 457-2136

Kevin McCutcheon

Kmccutcheon@paynewest.com

(406) 457-2111

Or contact

McKee Anderson MFDA President for any questions

mckee@mfda.biz

1-800-735-1082