Form FA 112 (1/14) - Application for Reimbursement

The Form 112 – Application for Reimbursement and supporting documentation may be submitted via upload through the Michigan Data Exchange Gateway (DEG), a secure website.

Note: Form 112’s uploaded to the DEG are submitted to a different Mailbox than the Workers’ Compensation Agency forms. If you already have a DEG account established use Mailbox: WCFUNDSA and Application ID: 112FA when uploading the Form 112.

Those interested in participating that do not have a DEG User Account can email Diane Harger at hargerd@michigan.gov. An account will be established and the necessary instructions on how to upload the Form 112 via the Michigan Data Exchange Gateway, including user ID, password, etc., will be provided.

Click for Form 112