Archive for the 'Workers Compensation Forms' Category

WC CALCULATIONS

Tuesday, January 13th, 2009

2009 Calculation Program
Version 10.0

Version 10.0 of the calculation program is now available. This includes rates for the year 2009. This is still a single user system. Please do not attempt to install in a networked environment and make accessible by more than one user, as both calculation and program errors will occur.  This application is also not supported in a Windows NT or Citrix environment. Click here  Calculation Program Help Manual to view the help manual which includes instructions on installing this program. It may be helpful to print these instructions before continuing. If you have a previous version of this program on your PC, it must be uninstalled first. Once you have printed and read the install instructions, click here setup.exe to download the new version to your computer. You MUST save this file to your hard drive and install it from there. The file size is almost 13MB, so it may take a few minutes depending upon the speed of your connection.  If you wish to install this program on more than one computer, you can save the setup.exe file to any external media (i.e., flash drive, CD, etc.).If you do not have internet access, you may obtain this program on CD-ROM. If you would like a copy, please send a letter to Sandra Adams at the Workers’ Compensation Agency, P.O. Box 30016, Lansing, Michigan 48909 . The letter must be accompanied by a padded, stamped ($1.65 worth of postage), self-addressed mailer at least 7″ x 9″ in size.

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 (2/04) – Plaintiff’s Application for Mediation or Hearing

-WC-104B (4/06) – Health Care Services Application for Mediation or Hearing (fill-in form)

-WC-104C (4/05) – Defendant’s Application for Mediation or Hearing

-WC-105 (8/08) Work History, Work Qualifications & Training Disclosure Questionnaire (fill-in form)

-WC-113 (1/04) – Redemption Order (fill-in form)

-WC-113A (8/05) – Multiple Carrier Redemption Form (fill-in form)

-WC-115 (5/05) – Voluntary Payment Form (fill-in form)

-WC-119 (8/05) – Affidavit in Support of Redemption (settlement) Agreement (fill-in form)

-WC-251 (8/05) – Carrier’s Response (fill-in form)

-WC-262 (4/05) – Claim/Cross-Claim for Review (fill-in form)

-WC-508 (2/07) – Subpoena for Production of Records (and/or) Witness Subpoena (fill-in form)

-WC-544 (7-05) – Worker’s Settlement Statement (fill-in form)

-WC-556 (5/05) – 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 (7/04) Self-Insurer Application Packet

-WC-402A (2/06) Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form)

-WC-402G (8/05) Group Self-Insurer Application Packet

-WC-402GR (1/04) Group Self-Insurer Application (fill-in form)

-WC-404 (1/04) Service Company Application (fill-in form)

-WC-650 (3/05) – Self-Insured Group Notice of Acceptance of Membership (fill-in form)

-WC-651 (3/05) – Notice of Termination of Membership (fill-in form)

-Letter of Credit/Memorandum of Understanding (8/08) (fill-in form)

-Michigan Continuous Surety Bond (12/03)

-Michigan Certificate of Specific/Aggregate Excess Liability Insurance (1/04)

-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 (10/05) – Employer’s Basic Report of Injury (fill-in form)

-WC-106 (7/05) – Supplemental Report of Fatal Injury (fill-in form)

-WC-107 (11/04) – Notice of Dispute (fill-in form)

-WC-108 (9/04) – Application for Advance Payment (fill-in form)

-WC-110 (3/05) – Report on Rehabilitation (fill-in form)

-WC-114 (8/05) – Application for Reimbursement from the Compensation Supplement Fund (fill-in form)

-WC-117 (9/05) – Employee’s Report of Claim (fill-in form)

-WC-500 (6/08) VR Provider Professional Disclosure Statement

-WC-701 (9/05) – Notice of Compensation Payments (fill-in form)

-Need to Know How to Complete a Form 701?

-WC-728 (8/05) – Amputation Chart