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A person receiving benefits under the state of michigan disability benefit program must reimburse the state any benefits paid under the program for which the recipient is ineligible because of benefits received from any source that require offset from disability benefits under the program’s terms. If the “date returned to work” is left blank, the claims team will contact you to determine wage loss benefit eligibility. Find all of the michigan workers' compensation forms & resources you need to file a claim.
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Use this form to report all regardless of medical treatment or disability If the employee has returned to work, be sure to complete the “date returned to work” question on the form Claim forms can be submitted directly online or by email, fax, or mail
Additional documentation may be submitted by email, fax, or mail
Enclosed you will find documentation necessary for the processing and administration of a claim in the event of a workplace injury, as well as important information regarding workers compensation requirements for your state (i.e Posting notices, compliance laws, etc). A copy of this form will be sent to your employer and their workers’ compensation insurance carrier Do not submit any medical reports with this form
Date of birth (mm/dd/yyyy) 4 Employee name (last, first, mi) 10 To submit forms via email, print the form and sign it physically, then scan the signed form. This form is available on the michigan department of labor and economic opportunity (leo) workers’ compensation agency (wca) website.
Use this form regardless of medical treatment or disability status
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