Claims Forms
- WC-100 (12/20) - Employer's Basic Report of Injury (fill-in form)
- WC-106 (8/19) - Supplemental Report of Fatal Injury (fill-in form)
- WC-107 (8/19) - Notice of Dispute (fill-in form)
- WC-108 (8/19) - Application for Advance Payment (fill-in form)
- WC-117 (8/19) - Employee's Report of Claim (fill-in form)
- WC-271 (8/19) Application for Reimbursement from the Medical Benefits Fund (fill-in form)
- WC-272 (01/22) - Application for First Responder Presumed Coverage (fill-in form)
- WC-701 (8/19) - Notice of Compensation Payments (fill-in form)
- Need to Know How to Complete a Form 701?
- WC-701 (7/12) - Filing Codes
- WC-728 (8/19) - Amputation Chart (fill-in form)
Health Care Services Forms
- Form CMS-1500
- WC-117H (8/19) Provider's Report of Claim & Request for Medical Payment
- 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
- WC-104B (8/19) - Health Care Services Application for Mediation or Hearing (fill-in form)
- WC-739 (8/19) Carrier's Explanation of Benefits
- WC-750 (8/19) Provider's Request for Reconsideration (fill-in form)
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)
- 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)
Las formas en el Español
- 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 (8/19) - Request for Compliance Hearing (fill-in form)
- WC-104A (12/20) - Application for Mediation or Hearing (fill-in form)
- WC-104B (8/19) - Health Care Services Application for Mediation or Hearing (fill-in form)
- WC-104C (8/19) - Defendant's Application for Mediation or Hearing (fill-in form)
- WC-105A (8/19) Work History, Work Qualifications & Training Disclosure Questionnaire (fill-in form)
- WC-105B (8/19) Employer Disclosure Questionnaire (fill-in form)
- WC-113 (8/19) - Redemption Order (fill-in form)
- WC-113A (8/19) - Multiple Carrier Redemption Form (fill-in form)
- WC-115 (8/19) - Voluntary Payment Form (fill-in form)
- WC-119 (8/19) - Affidavit in Support of Redemption (settlement) Agreement (fill-in form)
- WC-200 (09/20) - Opinion/Order (fill-in form)
- WC-251 (8/19) - Carrier's Response (fill-in form)
- WC-262 (09/20) - Claim/Cross-Claim for Review (fill-in form)
- WC-508 (8/19) - Subpoena for Production of Records (and/or) Witness Subpoena (fill-in form)
- WC-544 (12/21) - Worker's Settlement Statement (fill-in form)
- WC-556 (8/19) - Agreement to Redeem Liability (fill-in form)
- WC-556A (12/17) - 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 (8/19) Self-Insurer Application Packet (fill-in form)
- WC-402A (8/19) Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form)
- WC-402G (8/19) Group Self-Insurer Application Packet
- WC-402GR (8/19) Group Self-Insurer Application (fill-in form)
- WC-404 (8/19) Service Company Application (fill-in form)
- WC-650 (8/19) Self-Insured Group Notice of Acceptance of Membership (fill-in form)
- WC-651 (8/19) - Notice of Termination of Membership (fill-in form)
- Letter of Credit/Memorandum of Understanding (8/19) (fill-in form)
- Michigan Continuous Surety Bond (8/19) (fill-in form)
- Michigan Certificate of Specific/Aggregate Excess Liability Insurance (8/19) (fill-in form)
- Self-Insurer's Claims Transfer Agreement (fill-in form)
