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MICHIGAN WORKERS COMPENSATION PLACEMENT FACILITY SPECIFIC PERSON EXCLUSION FORM NAME OF ENTITY FEIN LEGAL FORM OF ENTITY Sole Proprietor Partnership Corporation Limited Liability Company PERSONS ELIGIBLE FOR EXCLUSION BY LEGAL ENTITY Spouse Child Parent Partner Executive Officers may elect exclusion if the corporation has ten or fewer stockholders and the exclusion is to be executed. Certified Resolution/Consent Form must also be completed. Compa.

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