Get MI CSCL/LSA-060 2013-2024

Double-sided rosters are preferred for multiple page reports. Rosters must contain the following information Agency name Agency license number Agency address and telephone number Name of License Holder Name of person preparing report their title and signature Alphabetical listing of employees that have been employed by your agency for the quarter. Employees are classified as follows Human Resource employees Those that are engaged in the installation maintenance alteration monitoring responding or servicing of security alarm systems Employee date of birth Employee hire date Employee termination date Total number of employee for quarter SWORN STATEMENT as follows I affirm that I am authorized to act on behalf of the above name agency and I verify that the information contained on this form is true complete and accurate to the best of my knowledge and belief. 2 Columns 0 through 5 line 15 must agree with the corresponding columns of Wkst. B line 24 CORF NO. TRANSPORTATION 1 Amount from Part I column 6 line 15 4 Unit cost multiplier for CORF A G costs Line 2 divided by line 3 multiply each amount in column 6 lines 2 through 14 Part I by the unit cost multiplier and enter the result on the corresponding line of column 7 ADMINISTRATIVE ALLOCATED A G SEE SUM OF COLS 6 7 05-00 COMPUTATION OF CORF COSTS PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION TOTAL COSTS FROM SUPP. Security alarm system contractor a sole proprietorship firm company partnership limited liability company or corporation engaged in the installation maintenance alteration monitoring or servicing of security alarm systems or who responds to a security alarm system. business services security alarm systems installs security alarm systems monitors or arranges for the monitoring of a security alarm system or responds to security alarm systems at the protected premises. Authority MCL 338. CSCL/LSA-060 12/13 Page 1 EMPLOYEE ROSTERS Licensees must submit employee rosters to the Department on a quarterly basis. Note A renewal application shall not be processed if the quarterly roster has not been received for each quarter of the preceding 2-year license period. Authority MCL 338. TRANSPORTATION 1 Amount from Part I column 6 line 15 4 Unit cost multiplier for CORF A G costs Line 2 divided by line 3 multiply each amount in column 6 lines 2 through 14 Part I by the unit cost multiplier and enter the result on the corresponding line of column 7 ADMINISTRATIVE ALLOCATED A G SEE SUM OF COLS 6 7 05-00 COMPUTATION OF CORF COSTS PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION TOTAL COSTS FROM SUPP. WKST. J-1 PT. B line 24 CORF NO. TRANSPORTATION 1 Amount from Part I column 6 line 15 4 Unit cost multiplier for CORF A G costs Line 2 divided by line 3 multiply each amount in column 6 lines 2 through 14 Part I by the unit cost multiplier and enter the result on the corresponding line of column 7 ADMINISTRATIVE ALLOCATED A G SEE SUM OF COLS 6 7 05-00 COMPUTATION OF CORF COSTS PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION TOTAL COSTS FROM SUPP. WKST. Rosters must contain the following information Agency name Agency license number Agency address and telephone number Name of License Holder Name of person preparing report their title and signature Alphabetical listing of employees that have been employed by your agency for the quarter. Employees are classified as follows Human Resource employees Those that are engaged in the installation maintenance alteration monitoring responding or servicing of security alarm systems Employee date of birth Employee hire date Employee termination date Total number of employee for quarter SWORN STATEMENT as follows I affirm that I am authorized to act on behalf of the above name agency and I verify that the information contained on this form is true complete and accurate to the best of my knowledge and belief. Print Name of Person Performing Report Signature Title and Date You are required to file a roster form for each branch facility A roster is required even if your company does not have any employees. Transitional Requirements for the Conversion of Medicare 21 TexReg 4212 May 14 1996 Texas Register Alicia M. Fechtel General Counsel and Chief Clerk and Individual Accident and Health Insurance Required Disclosure Statement for Policies that are not Medicare Supplement Policies 28 TAC 3. 3614 the required disclosure statement for policies that are not Medicare Subchapter T of this chapter to Subchapter W of this chapter the notice requirements for the content and format of the required disclosure statement which must be provided to inform prospective buyers of health insurance policies about the nature and character of certain health coverages that are not Medicare supplement coverages. .