Form FIS0170 "Mcl 500.3163 No-Fault Certification" - Michigan

What Is Form FIS0170?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2013;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FIS0170 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0170 "Mcl 500.3163 No-Fault Certification" - Michigan

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FIS 0170 (04/13) Department of Insurance and Financial Services
MCL 500.3163 No-Fault Certification
NAIC Company Number
Name of company
Address
City
State
Postal code
hereby certifies that any accidental bodily injury or property damage occurring in the state of Michigan on or
after October 1, 1973, arising from the ownership, operation, maintenance or use of a motor vehicle as a motor
vehicle by a resident of Canada or any state of the United States of America, other than Michigan, who is
insured under any automobile liability policy issued by said company shall be subject to the personal and
property protection insurance system set forth in Chapter 31 of the Michigan Insurance Code. Such
certification is further conditioned to the extent that if such policy also provides direct benefits without regard to
fault pursuant to contractual agreement, the law of Canada or the law of such other state or territory, then (1)
the personal and property protection insurance benefits provided for in accordance with this certification shall
not apply to the extent that benefits for the same elements of loss are paid, payable or required to be provided
under such contractual agreement, the law of Canada or the law of such other state or territory, and (2) the
total amounts of personal and property protection insurance benefits which would be payable in accordance
with this certification shall be reduced by the amount paid, payable or required to be provided for the same
elements of loss under such contractual agreement, the law of Canada or the law of such other state or
territory.
Signature
Date signed
Name and title typed or printed
PA 218 of 1956 as amended requires submission of this form by companies writing automobile insurance in Michigan. Failure to complete and submit
this form properly could result in denial of your application or revocation of your authority as an admitted company in Michigan.
FIS 0170 (04/13) Department of Insurance and Financial Services
MCL 500.3163 No-Fault Certification
NAIC Company Number
Name of company
Address
City
State
Postal code
hereby certifies that any accidental bodily injury or property damage occurring in the state of Michigan on or
after October 1, 1973, arising from the ownership, operation, maintenance or use of a motor vehicle as a motor
vehicle by a resident of Canada or any state of the United States of America, other than Michigan, who is
insured under any automobile liability policy issued by said company shall be subject to the personal and
property protection insurance system set forth in Chapter 31 of the Michigan Insurance Code. Such
certification is further conditioned to the extent that if such policy also provides direct benefits without regard to
fault pursuant to contractual agreement, the law of Canada or the law of such other state or territory, then (1)
the personal and property protection insurance benefits provided for in accordance with this certification shall
not apply to the extent that benefits for the same elements of loss are paid, payable or required to be provided
under such contractual agreement, the law of Canada or the law of such other state or territory, and (2) the
total amounts of personal and property protection insurance benefits which would be payable in accordance
with this certification shall be reduced by the amount paid, payable or required to be provided for the same
elements of loss under such contractual agreement, the law of Canada or the law of such other state or
territory.
Signature
Date signed
Name and title typed or printed
PA 218 of 1956 as amended requires submission of this form by companies writing automobile insurance in Michigan. Failure to complete and submit
this form properly could result in denial of your application or revocation of your authority as an admitted company in Michigan.