LEO Labor and Economic Opportunity

Forms

Forms

Form Requirements

Optical Character Recognition (OCR) Requirements

File Transfer Service (FTS)
Claims Forms

WC-100 - Employer's Basic Report of Injury (fill-in form)

WC-106 - Supplemental Report of Fatal Injury (fill-in form)

WC-107 - Notice of Dispute (fill-in form)

WC-108 - Application for Advance Payment (fill-in form)

WC-117 - Employee's Report of Claim (fill-in form)

WC-271 - Application for Reimbursement from the Medical Benefits Fund (fill-in form)

WC-272 - Application for First Responder Presumed Coverage (fill-in form)

WC-701 - Notice of Compensation Payments (fill-in form)

How to Complete Form WC-701

WC-701 Filing Codes

WC-728 - Amputation Chart (fill-in form)
Compensation Supplement Fund

WC-114 Compensation Supplement Fund Application (fill-in form)

Compensation Supplement Fund Reimbursement Periods
Funds Administration Forms

FA-112 - Application for Reimbursement
Health Care Services Forms

Form CMS-1500

WC-117H - Provider's Report of Claim and Request for Medical Payment

WC-581 - Application for Adjustment to the Workers' Compensation Maximum Payment Ratio

WC-590 - Application for Certification of a Carrier's Professional Health Care Review Program

WC-104B - Health Care Services Application for Mediation or Hearing (fill-in form)

WC-739 - Carrier's Explanation of Benefits

WC-750 - Provider's Request for Reconsideration (fill-in form)
Insurance Coverage Forms

WC-337 - Notice of Exclusion

WC-338 - Notice to Terminate Exclusion

WC-400 - Insurer's Notice of Issuance of Policy (fill-in form)

WC-400A - Insurer's Notice of Issuance of Specific Risk Policy

WC-401 - Notice of Termination of Liability (fill-in form)

WC-401A - Notice of Termination of Specific Risk Policy

WC-403 - Insurer's Notice of Name or Address Change (fill-in form)
Las Formas En El Espanol

WC-104A (Español) - Solicitud Para Mediación O Audiencia - Formulario A

WC-113 (Español) - Demanda de Redención

WC-117 (Español) - Informe de Reclamación Del Empleado

WC-119 (Español) - Declaracion que Apoya el Acuerdo de Redencion

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

WC-544 (Español) - Declaración del Acuerdo del Trabajador

WC-556 (Español) - Acuerdo Para Redimir Responsabilidad
Litigation Forms

WC-40 - Request for Compliance Hearing (fill-in form)

WC-104A - Application for Mediation or Hearing (fill-in form)

WC-104B - Health Care Services Application for Mediation or Hearing (fill-in form)

WC-104C - Defendant's Application for Mediation or Hearing (fill-in form)

WC-105A - Work History, Work Qualifications and Training Disclosure Questionnaire (fill-in form)

WC-105B - Employer Disclosure Questionnaire (fill-in form)

WC-113 - Redemption Order (fill-in form)

WC-113A - Multiple Carrier Redemption Form (fill-in form)

WC-115 - Voluntary Payment Form (fill-in form)

WC-119 - Affidavit in Support of Redemption (settlement) Agreement (fill-in form)

WC-200 - Opinion/Order (fill-in form)

WC-251 - Carrier's Response (fill-in form)

WC-262 - Claim/Cross-Claim for Review (fill-in form)

WC-508- Subpoena for Production of Records (and/or) Witness Subpoena (fill-in form)

WC-544 - Worker's Settlement Statement (fill-in form)

WC-556 - Agreement to Redeem Liability (fill-in form)

WC-556A - Addendum to Agreement to Redeem Liability (fill-in form)
Miscellaneous Forms

WC-155 - Authorization for Release of Records (fill-in form)

WC-450 - Application for Authorization by Self-Insured Employer or Group Fund for Servicing Agent FTS User Account (fill-in form)

WC-460 - Application for FTS User Account for Carriers and Self-Insured Employers (fill-in form)

WC-480 - Application for FTS User Account for Attorneys (fill-in form)
Self-Insurance Forms

WC-402 - Self-Insurer Application Packet (fill-in form)

WC-402A - Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form)

WC-402G - Group Self-Insurer Application Packet

WC-402GR - Group Self-Insurer Application (fill-in form)

WC-404 - Service Company Application (fill-in form)

WC-650 - Self-Insured Group Notice of Acceptance of Membership (fill-in form)

WC-651 - Notice of Termination of Membership (fill-in form)

Letter of Credit/Memorandum of Understanding (fill-in form)

Michigan Continuous Surety Bond (fill-in form)

Michigan Certificate of Specific/Aggregate Excess Liability Insurance (fill-in form)

Self-Insurer's Claims Transfer Agreement (fill-in form)
Vocational Rehabilitation Forms

WC-500 - VR Provider Professional Disclosure Statement

WC-502 - Application for Agency Approval as a Rehabilitation Facility (fill-in form)