Archive for October, 2008

Workers’ Compensation Litigation Forms

Wednesday, October 29th, 2008

In an effort to assist our clients, we have placed links here to locate specific litigation documents at the Michigan Workers’ Compensation Agency. Clicking on a link below will cause you to navigate away from this site briefly in order to open or download the PDF form from the WCA site. To ensure the most current versions of form, you may wish to visit WCA directly. (This link will open in a new window.)

-WC-104A – Plaintiff’s Application for Mediation or Hearing

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

-WC-104C – Defendant’s Application for Mediation or Hearing

-WC-105 – Work History, Work Qualifications & Training 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-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)

Self-Insured Forms

Wednesday, October 29th, 2008

In an effort to assist our clients, we have placed links here to locate specific claim documents pertaining to Self-Insured companies at the Michigan Workers’™ Compensation Agency. Clicking on a link below will cause you to navigate away from this site briefly in order to open or download the PDF form from the WCA site. To ensure the most current versions of form, you may wish to visit WCA directly. (This link will open in a new window.)

-WC-402 Self-Insurer Application Packet

-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

-Michigan Certificate of Specific/Aggregate Excess Liability Insurance

-Self-Insurer’s Claims Transfer Agreement

Workers’ Compensation Claim Forms

Wednesday, October 29th, 2008

In an effort to assist our clients, we have placed links here to locate specific claim documents at the Michigan Workers’ Compensation Agency. Clicking on a link below will cause you to navigate away from this site briefly in order to open or download the PDF form from the WCA site. To ensure the most current versions of form, you may wish to visit WCA directly. (The link will open in a new window.)
-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-110 – Report on Rehabilitation (fill-in form)

-WC-114 – Application for Reimbursement from the Compensation Supplement Fund (fill-in form)

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

-WC-500 – VR Provider Professional Disclosure Statement

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

-Need to Know How to Complete a Form 701?

-WC-728 – Amputation Chart