Workers’ Compensation Claim Forms

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