The MPCGA is not an insurance company, and the statutory coverage provided by the MPCGA pursuant to the Property and Casualty Guaranty Association Act, MCL 500.7901 et seq., may not coincide with the coverage available under the policy of the insolvent carrier. In order to assist us in determining coverage we ask that you complete the Statement of Claim. In addition to the Statement of Claim, you may also be required to complete other forms pertaining to your loss such as the Auto – Personal Injury Protection (PIP) or Workers’ Compensation forms.

If there are multiple claims or claim types, a separate Statement of Claim form must be completed for each claim or claim type.

The following forms require Adobe Reader. Please download and complete the form pertaining to your loss in its entirety.

Mail the completed form to:

PO Box 531266
Livonia, MI 48153-1266

Auto – Personal Injury Protection (PIP)


Statement of Claim


Workers Compensation (WC)