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MLCC Proof of Financial Responsibility Form LC 95 Michigan

MLCC Proof of Financial Responsibility Form LC 95 Michigan

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Be signed by all partners or co-licensees on the license. Licensees having more than one licensed location must file a separate 5. If MLCC form LC-95 is used the authorized agent must enter the information requested and sign the form at the bottom. The signature certifies to the MLCC that the insurance policy is for an amount of at least 50 000 and that it complies with the provisions of MCL 436. Insurance Policy Number Effective Date Insurance Company Name and Address CONSTANT VALUE BOND The...
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