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    Claims Forms

    • WC-100 (2/13) - Employer's Basic Report of Injury (fill-in form) PDF icon

    • WC-106 (10/11) - Supplemental Report of Fatal Injury (fill-in form) PDF icon

    • WC-107 (2/13) - Notice of Dispute (fill-in form) PDF icon

    • WC-108 (11/11) - Application for Advance Payment (fill-in form) PDF icon

    • WC-114 (11/11) - Application for Reimbursement from the Compensation Supplement Fund (fill-in form) PDF icon

    • WC-117 (4/13) - Employee's Report of Claim (fill-in form) PDF icon

    • WC-701 (2/13) - Notice of Compensation Payments (fill-in form)

    • WC-701 (7/12) - Filing Codes PDF icon

    • Need to Know How to Complete a Form 701? PDF icon

    • WC-728 (12/11) - Amputation Chart (fill-in form) PDF icon


    Funds Administration Forms

    • WC-FA112(2/12) Application for Reimbursement (from the Funds Administration) (fill-in form) PDF icon

    • WC-271 (4/11) Application for Reimbursement from the Medical Benefits Fund (fill-in form) PDF icon


    Health Care Services Forms

    • WC-104B (9/13) - Health Care Services Application for Mediation or Hearing (fill-in form) PDF icon

    • WC-117H (1/12) Provider's Report of Claim & Request for Medical Payment PDF icon

    • WC-739 (2/12) Carrier's Explanation of Benefits PDF icon


    Insurance Coverage Forms

    • WC-337 (6/09) Notice of Exclusion

    • WC-338 (7/09) Notice to Terminate Exclusion

    • WC-400 (2/13) - Insurer's Notice of Issuance of Policy (fill-in form) PDF icon

    • WC-400A (7/09) - Insurer's Notice of Issuance of Specific Risk Policy

    • WC-401 (2/13) - Notice of Termination of Liability (fill-in form) PDF icon

    • WC-401A (7/09) - Notice of Termination of Specific Risk Policy

    • WC-403 (9/13) - Insurer's Notice of Name or Address Change (fill-in form) PDF icon


    Las formas en el Español

    • BWC-113 (Español) - Demanda de Redención PDF icon

    • BWC-119 (Español) - Declaracion que Apoya el Acuerdo de Redencion PDF icon

    • WC-500 (Español) - Proveedor de Rehabilitación Vocacional Declaración de Divulgación Profesional PDF icon

    • BWC-544 (Español) - Declaración del Acuerdo del Trabajador PDF icon

    • BWC-556 (Español) - Acuerdo Para Redimir Responsabilidad PDF icon


    Litigation Forms

    • WC-40 (1/12) - Request for Compliance Hearing (fill-in form) PDF icon

    • WC-104A (2/13) - Application for Mediation or Hearing (fill-in form)

    • WC-104B (9/13) - Health Care Services Application for Mediation or Hearing (fill-in form) PDF icon

    • WC-104C (2/12) - Defendant's Application for Mediation or Hearing (fill-in form) PDF icon

    • WC-105A (4/12) Work History, Work Qualifications & Training Disclosure Questionnaire (fill-in form) PDF icon

    • WC-105B (4/12) Employer Disclosure Questionnaire (fill-in form) PDF icon

    • WC-113 (4/12) - Redemption Order (fill-in form) PDF icon

    • WC-113A (4/12) - Multiple Carrier Redemption Form (fill-in form) PDF icon

    • WC-115 (9/13) - Voluntary Payment Form (fill-in form) PDF icon

    • WC-119 (4/12) - Affidavit in Support of Redemption (settlement) Agreement (fill-in form) PDF icon

    • WC-200 (4/12) - Opinion/Order (fill-in form)

    • WC-251 (4/12) - Carrier's Response (fill-in form) PDF icon

    • WC-262 (4/12) - Claim/Cross-Claim for Review (fill-in form) PDF icon

    • WC-508 (1/12) - Subpoena for Production of Records (and/or) Witness Subpoena (fill-in form) PDF icon

    • WC-544 (5/12) - Worker's Settlement Statement (fill-in form) PDF icon

    • WC-556 (5/12) - Agreement to Redeem Liability (fill-in form) PDF icon


    Self-Insurance Forms

    • WC-402 (8/11) Self-Insurer Application Packet (fill-in form) PDF icon

    • WC-402A (8/11) Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form) PDF icon

    • WC-402G (9/11) Group Self-Insurer Application Packet PDF icon

    • WC-402GR (9/11) Group Self-Insurer Application (fill-in form) PDF icon

    • WC-404 (9/11) Service Company Application (fill-in form) PDF icon

    • WC-650 (9/11) Self-Insured Group Notice of Acceptance of Membership (fill-in form) PDF icon

    • WC-651 (9/11) - Notice of Termination of Membership (fill-in form) PDF icon

    • Letter of Credit/Memorandum of Understanding (8/11) (fill-in form) PDF icon

    • Michigan Continuous Surety Bond (8/11) (fill-in form) PDF icon

    • Michigan Certificate of Specific/Aggregate Excess Liability Insurance (8/11) (fill-in form) PDF icon

    • Self-Insurer's Claims Transfer Agreement (fill-in form) PDF icon


    Vocational Rehabilitation Forms

    • WC-110 (11/11) - Report on Rehabilitation (fill-in form) PDF icon

    • WC-500 (12/11) VR Provider Professional Disclosure Statement PDF icon

    • WC-502 (5/12) - Application for Agency Approval as a Rehabilitation Facility (fill-in form) PDF icon




    WCA Quicklinks
     •  2013 Calculation Program
     •  Insurance Coverage Lookup
     •  Hearing Site Clickable Map
     •  State Average Weekly Wage Chart
     •  Travel Reimbursement Rates
     •  Magistrate Opinions Search
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