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Michigan Form Center -

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Form

Description

wc100.pdf OCR-Employer's Basic Report of Injury
bwc106.pdf Supplemental Report of Fatal Injury
bwc107.pdf OCR-Notice of Dispute
bwc108.pdf Application for Advance Payment
bwc110.pdf Report on Rehabilitation
bwc114.pdf Application for Reimbursment from the Compensation Supplement Fund
wc117.pdf Employee's Report of Claim
wc500.pdf Vocational Rehab Provider Professional Disclosure Statement
wc500sp.pdf Proveedor De Rehabilitacion Vocacional Declaracion De Divulgacion Profesional
wc701.pdf OCR-Notice of Compensation Payments - This is a double-sided form (2nd page was updated 4/13)
wc701codes.pdf WC-701 Filing Codes
wc701inst.pdf WC-701 Instructions
wc728.pdf Amputation Chart
bwc112.pdf Application for Reimbursement (from Funds Administration)
bwc271.pdf Application for Reimbursement from the Medical Benefit Fund
wc104b.pdf Application for Mediation Or Hearing – Form B
wc117h.pdf Provider's Report of Claim & Request for Medical Payment
wc406.pdf Annual Medical Payment Report - The form must now be submitted electronically through the agency's website.
wc590.pdf Application for Certification of a Carrier's Professional Health Care Review Program
wc739.pdf Carrier's Explanation of Benefits
WC-337 Notice of Exclusion - Not available online. To obtain a copy of the form, contact the Compliance & Employer Records Division at (517) 322-1195.
wc338.pdf Notice to Terminate Exclusion
wc400.pdf OCR-Insurer's Notice of Issuance of Policy
WC-400a Insurer's Notice of Issuance of Specific Risk Policy - This form is not available online. To obtain a copy of this form, contact the Compliance & Employer Records Division at (517) 322-1195.
wc401.pdf OCR-Notice of Termination of Liability
WC-401a Notice of Termination of Liability - This form is not available online. To obtain a copy of this form, contact the Compliance & Employer Records Division at (517) 322-1195.
wc403.pdf Insurer's Notice of Name or Address Change
bwc113sp.pdf Demanda de Redención (Redemption Order) - Para la Referencia Sólo
bwc119sp.pdf Declaracion que Apoya el Acuerdo de Redencion (Affidavit in Support of Redemption (settlement) Agreement) - Para la Referencia Sólo
bwc544sp.pdf Declaración Del Acuerdo Del Trabajador
bwc556sp.pdf Acuerdo Para Redimir Responsabilidad (Agreement to Redeem Liability)
wc40.pdf Request for Compliance Hearing
wc104a.pdf OCR-Application for Mediation or Hearing
wc104c.pdf Application for Mediation Or Hearing — Form C
wc105a.pdf Work History, Work Qualifications & Training Disclosure Questionnaire
wc105b.pdf Employer Disclosure Questionnaire
wc113.pdf Redemption Order
wc113a.pdf Multiple Carrier Redemption Form
wc115.pdf Voluntary Payment Form
wc119.pdf Affidavit in Support of Redemption (Settlement) Agreement
wc200.pdf Opinion / Order Must be printed on green paper
wc251.pdf Carrier's Response
wc262.pdf Claim for Review
wc508.pdf Witness Subpoena (and/or) Subpoena for Production of Records
wc544.pdf Worker's Settlement Statement
wc556.pdf Agreement to Redeem Liability
wc450.pdf Application For Authorization By Self-Insured Employer or Group Fund For Servicing Agent DEG User Account
wc460.pdf Application For DEG User Account
wc402.pdf Self-Insurer Application
wc402a.pdf Self-Insurer Request to Add or Delete Subsidiary/Affiliate
wc402g.pdf Group Self-Insurer Application Packet
wc402gr.pdf Workers' Disability Compensation Group Self-Insurer Application Packet
wc402pkt.pdf Workers' Disability Compensation Self-Insurer Application Packet
wc404.pdf Bureau of Workers' Disability Compensation Service Company Application
wc650.pdf Group Self-Insurance Notice of Acceptance of Membership
wc651.pdf Notice of Termination of Membership
letterofcredit.pdf Letter of Credit/Memorandum of Understanding
suretybond.pdf Michigan Continuous Surety Bond
coeli.pdf Michigan Certificate of Specific/Aggregate Excess Liability Insurance
ClaimsTransfer.pdf Self-Insurer's Claims Transfer Agreement
miosha-300-300a-301.xls MIOSHA Recordkeeping Forms 300, 300A and 301 for 2004 (Excel Spreadsheet Version) Forms are Microsoft Excel 2000 spreadsheets and formatted to legal-sized document. To print, computers/printers must be capab;e of utilizing both of these features.
wca_fact_sheet.pdf BROCHURE - Workers' Compensation in Michigan
WC-PUB-005.pdf POSTER - Employees -- Know Your Rights!
WC-PUB-006.pdf POSTER - Workers Compensation Agency - Rights & Responsibilities