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Labor and Economic Opportunity
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Forms

Forms Requirements

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  • Data Exchange Gateway (DEG)

Claims Forms

  • WC-100 (8/19) - Employer's Basic Report of Injury (fill-in form)
  • WC-106 (8/19) - Supplemental Report of Fatal Injury (fill-in form) PDF icon
  • WC-107 (8/19) - Notice of Dispute (fill-in form)
  • WC-108 (8/19) - Application for Advance Payment (fill-in form) PDF icon
  • WC-117 (8/19) - Employee's Report of Claim (fill-in form) PDF icon
  • WC-271 (8/19) Application for Reimbursement from the Medical Benefits Fund (fill-in form) PDF icon
  • WC-272 (8/19) - Application for First Responder Presumed Coverage (fill-in form) PDF icon
  • WC-701 (8/19) - Notice of Compensation Payments (fill-in form)
  • Need to Know How to Complete a Form 701? PDF icon
  • WC-701 (7/12) - Filing Codes PDF icon
  • WC-728 (8/19) - Amputation Chart (fill-in form) PDF icon

Compensation Supplement Fund

  • WC-114 Compensation Supplement Fund fill-in form
  • Compensation Supplement Fund Reimbursement Periods PDF icon

Funds Administration Forms

  • Form FA 112 (8/19) - Application for Reimbursement

Health Care Services Forms

  • Form CMS-1500 PDF icon
  • WC-104B (8/19) - Health Care Services Application for Mediation or Hearing (fill-in form) PDF icon
  • WC-117H (8/19) Provider's Report of Claim & Request for Medical Payment PDF icon
  • WC-581 (8/19) - Application for Adjustment to the Workers' Compensation Maximum Payment Ratio
  • WC-590 Application for Certification of a Carrier's Professional Health Care Review Program PDF icon
  • WC-739 (8/19) Carrier's Explanation of Benefits PDF icon
  • WC-750 (8/19) Provider's Request for Reconsideration (fill-in form) PDF icon

Insurance Coverage Forms

  • WC-337 (12/15) Notice of Exclusion
  • WC-338 (4/13) Notice to Terminate Exclusion
  • WC-400 (8/19) - Insurer's Notice of Issuance of Policy (fill-in form)
  • WC-400A (8/19) - Insurer's Notice of Issuance of Specific Risk Policy
  • WC-401 (8/19) - Notice of Termination of Liability (fill-in form) PDF icon
  • WC-401A (8/19) - Notice of Termination of Specific Risk Policy
  • WC-403 (8/19) - Insurer's Notice of Name or Address Change (fill-in form) PDF icon

Las formas en el Español

  • WC-104A (Español) - Solicitud Para Mediación O Audiencia - Formulario A PDF icon
  • WC-113 (Español) - Demanda de Redención PDF icon
  • WC-117 (Español) - Informe de Reclamación Del Empleado PDF icon
  • WC-119 (Español) - Declaracion que Apoya el Acuerdo de Redencion PDF icon
  • WC-500 (Español) - Proveedor de Rehabilitación Vocacional Declaración de Divulgación Profesional PDF icon
  • WC-544 (Español) - Declaración del Acuerdo del Trabajador PDF icon
  • WC-556 (Español) - Acuerdo Para Redimir Responsabilidad PDF icon

Litigation Forms

  • WC-104B (8/19) - Health Care Services Application for Mediation or Hearing (fill-in form) PDF icon
  • WC-40 (8/19) - Request for Compliance Hearing (fill-in form) PDF icon
  • WC-104A (8/19) - Application for Mediation or Hearing (fill-in form)
  • WC-104C (8/19) - Defendant's Application for Mediation or Hearing (fill-in form) PDF icon
  • WC-105A (8/19) Work History, Work Qualifications & Training Disclosure Questionnaire (fill-in form) PDF icon
  • WC-105B (8/19) Employer Disclosure Questionnaire (fill-in form) PDF icon
  • WC-113 (8/19) - Redemption Order (fill-in form) PDF icon
  • WC-113A (8/19) - Multiple Carrier Redemption Form (fill-in form) PDF icon
  • WC-115 (8/19) - Voluntary Payment Form (fill-in form) PDF icon
  • WC-119 (8/19) - Affidavit in Support of Redemption (settlement) Agreement (fill-in form) PDF icon
  • WC-200 (08/19) - Opinion/Order (fill-in form)
  • WC-251 (8/19) - Carrier's Response (fill-in form) PDF icon
  • WC-262 (8/19) - Claim/Cross-Claim for Review (fill-in form) PDF icon
  • WC-508 (8/19) - Subpoena for Production of Records (and/or) Witness Subpoena (fill-in form) PDF icon
  • WC-544 (8/19) - Worker's Settlement Statement (fill-in form) PDF icon
  • WC-556 (8/19) - Agreement to Redeem Liability (fill-in form) PDF icon
  • WC-556A (12/17) - Addendum to Agreement to Redeem Liability (fill-in form) PDF icon

Miscellaneous Forms

  • WC-155 Authorization for Release of Records (fill-in form) PDF icon
  • WC-450 Application For Authorization By Self-Insured Employer or Group Fund For Servicing Agent DEG User Account (fill-in form) PDF icon
  • WC-460 Application For DEG User Account (fill-in form) PDF icon
  • WC-470 Application For DEG User Account-104's (fill-in form) PDF icon

Self-Insurance Forms

  • WC-402 (8/19) Self-Insurer Application Packet (fill-in form) PDF icon
  • WC-402A (8/19) Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form) PDF icon
  • WC-402G (8/19) Group Self-Insurer Application Packet PDF icon
  • WC-402GR (8/19) Group Self-Insurer Application (fill-in form) PDF icon
  • WC-404 (8/19) Service Company Application (fill-in form) PDF icon
  • WC-650 (8/19) Self-Insured Group Notice of Acceptance of Membership (fill-in form) PDF icon
  • WC-651 (8/19) - Notice of Termination of Membership (fill-in form) PDF icon
  • Letter of Credit/Memorandum of Understanding (8/19) (fill-in form) PDF icon
  • Michigan Continuous Surety Bond (8/19) (fill-in form) PDF icon
  • Michigan Certificate of Specific/Aggregate Excess Liability Insurance (8/19) (fill-in form) PDF icon
  • Self-Insurer's Claims Transfer Agreement (fill-in form) PDF icon

Vocational Rehabilitation Forms

  • WC-110 (8/19) - Report on Rehabilitation (fill-in form) PDF icon
  • WC-500 (8/19) VR Provider Professional Disclosure Statement PDF icon
  • WC-502 (8/19) - Application for Agency Approval as a Rehabilitation Facility (fill-in form) PDF icon

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Labor and Economic Opportunity