Fill - EMPLOYER'S BASIC REPORT OF INJURY (National American Insurance Company)

EMPLOYER'S BASIC REPORT OF INJURY

Michigan Department of Licensing and Regulatory Affairs

Workers’ Comp

ensation Agency

PO Box 30016, Lansing, MI 48909

An employer shall report immediately to the agency on Form WC-100 all injuries, including diseases, which arise out of and in the course of the employment, or on which a claim is

made and result in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific losses. In case of death, an

employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures.

I. EMPLOYEE DATA

1. Social Security Number 2. Date of injury 3. Employee name (Last, First, MI)

4. Address (Number & Street) 5. City 6. State 7. ZIP Code

8. Date of birth (MM/DD/YYYY) 9. Sex 10. Number of dependents 11. Telephone number

Male

Female

12. Tax filing status: A. Single B. Single, Head of Household C. Married, Filing Joint D. Married, Filing Separate

II. EMPLOYER/CARRIER DATA

13. Employer name 14. Federal ID Number

15. Injury location code 16. Mailing location code 17. UI number 18. Type of business (SIC/NAICS)

19. Employer street address 20. City 21. State 22. ZIP code

23. Insurance company name (if employer not self-insured) 24. Insurance company telephone number (if known)

III. INJURY/MEDICAL DATA

25. Last day worked 26. Date employee returned to work (if applicable) 27. Did employee die? 28. If yes, date of death

Yes No

29. Injury city 30. Injury state 31. Injury county 32. Did injury occur on employer's premises?

Yes No (If no, see item 53)

33. Case number from OSHA/MIOSHA log 34. Time employee began work 35. Time of event

a.m. p.m. a.m. p.m.

If time cannot be determined,

check here

36. What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.

37. How did the injury occur? Examples: “When ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during replacement”

38. Describe the nature of injury or illness 39. Part of body directly affected by the injury or illness

40. What object or substance directly harmed the employee? Examples: concrete floor, chlorine, radial arm saw. If this question does not apply to the incident, leave it blank.

41. Name of physician or other health care professional 42. Was employee treated in an emergency room? 43. Was employee hospitalized overnight as an in-patient?

Yes No Yes No

44. If treatment was given away from the worksite, where was it given? (Include name, address, city, state and ZIP code of facility)

IV. OCCUPATION AND WAGE DATA

45. Date hired 46. Total gross weekly wage (highest 39 of 52) 47. Number of weeks used 48. Value of discontinued fringes

49. Occupation (Be specific) 50. Was employee a volunteer worker? 51. Was employee certified as vocationally handicapped?

Yes No

52. Date employer notified by employee 53. If temporary service agency, provide name/address of employer where injury occurred.

V. PREPARER DATA I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE

Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits.

54. Preparer's name (Please print or type) 55. Preparer's signature 56. Telephone number 57. Date prepared

Notice to employee: Questions or errors should be reported immediately to the individual listed above in space 54

WC-100 (Rev. 2/13) Front

Go to Instructions

Reset

OCR 100

If you are using this form as a replacement for the Form 301 to document the specifics of an injury or ill ness for

purposes of compliance with the work-related injury and illness logging requirements, follow the instructions in

Section A only.

If you are using this form to report a workers’ compensation injury, follow the instructions in Section A and B.

Section A

This form can be used in lieu of the MIOSHA Form 301, Injury and Illness Incident Report. It is one of the first

forms you must fill out when a re cordable work-related injury or il lness has occurred. Together with the Log of

Work-Related Injuries and Illnesses (Form 300) and the accompanying Summary (Form 300A), these forms help

the employer and MIOSHA develop a picture of the extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred,

you must fill out questions 1-9, 27-28, 33-45 and 54-57.

According to Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974,

Part 11, Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, you must keep this

form on file for 5 years following the year to which it pertains.

DO NOT mail this form to the Workers’

Compensation Agency unless it meets the conditions listed below in Section B.

Section B

You must complete all questions on this form if the injury or disease results in any of the following: (a) Disability

extending beyond seven (7) consecutive days, not including the date of injury; (b ) Death; (c) Specific lo ss. The

original form must be mailed to the Workers’ Compensation Agency, P.O. Box 30016, Lansing, MI 48909.

Authority: Workers' Disability Compensation Act, 408.31(1)(3)

Completion:

Mandatory

Penalty: Workers' Disability Compensation Act, 418.631

LARA is an equal opportunit y employer/program. Auxiliary aids,

services and other reasonable accommodations are available upon

request to individuals with disabilities.

WC-100 (Rev. 10/11) Back

Go to Page 1

SUPPLEMENTAL REPORT OF FATAL INJURY

Michigan Department of Licensing and Regulatory Affairs

Workers' Compensation Agency

PO Box 30016, Lansing, MI 48909

THIS REPORT IS TO BE FILED BY THE EMPLOYER IMMEDIATELY AFTER THE DEATH OF AN INJURED EMPLOYEE.

I. DECEASED EMPLOYEE

1. Social Security Number 2. Date of Injury 3. Date of Death

4. Name (Last, First, Middle Initial)

5. Street Address 6. City 7. State 8. ZIP Code

II. EMPLOYER DATA

9. Employer Name 10. Federal I.D. Number

11. Street Address 12. City 13. State 14. ZIP Code

15. Amount of Burial Expenses Paid (If Not Previously Reported)

III. DEPENDENTS OF EMPLOYEE

16.

Name

17.

Date of Birth

18.

Relationship to Deceased

(Spouse, Child, or Other - Please Specify Other)

19.

Extent of Dependency

(Total/Partial)

20. Employer’s Signature 21. Title 22. Date

Authority:

Completion:

Penalty:

Workers’ Disability Compensation Act, R408.31(3)

Mandatory

Workers’ Disability Compensation Act 418.631

LARA is an equal opportunity employer/program. Auxiliary aids, services and

other reasonable accommodations are available upon request to individuals

with disabilities.

WC-106 (10/11)

Reset

EMPLOYEE’S REPORT OF CLAIM

Michigan Department of Licensing and Regulatory Affairs

Workers’ Compensation Agency

P.O. Box 30016, Lansing, MI 48909

NOTE: 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.

1. Social Security Number 2. Date of Injury 3. Date of Birth (MM/DD/YYYY) 4. Employee Telephone Number

5. Employee Name (Last, First, MI) 10. Employer Name

6. Employee Street Address

11. Employer Street Address

7. Employee City

8. State

9. ZIP Code

12. Employer City

13. State

14. ZIP Code

15. Describe the type of injury and explain how it happened.

16. Are you making a claim for payment of medical expenses?

Yes No

17.

Last Day Worked

18. Have you gone back to work? Yes No

If yes, date of return ______________________________

19. Was the injury reported to your employer? Yes No

If yes, date reported ______________________________

Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in

criminal or civil prosecution, or both, and denial of benefits.

20. Employee Signature

21. Date of this report

OFFICE USE ONLY

Carrier Name

LARA is an equal opportunity employer/program. Auxiliary aids, services and other

reasonable accommodations are available upon request to individuals with disabilities.

Authority:

Completion:

Penalty:

Workers’ Disability Compensation Act, 408.31(4)

Voluntary

None

WC-117 (Rev. 4/13)

Reset

State of Michigan

Workers' Compensation Agency

Employees -- Know Your Rights!

 Remember - It is important to report your injury to your employer.

 Medical Care

You are entitled to reasonable and necessary medical care for work-related injuries or diseases. Employers or their

insurance carriers are required by law to provide these services. During the first 28 days of treatment, your employer

has the right to choose the physician. After 28 days you are free to change physicians, but you must notify your

employer of the change. If you receive treatment from a physician of your choice, you shall obtain and promptly

furnish a report to your employer.

If your employer refuses to provide medical care, you should contact Michigan’s Workers’ Compensation Agency at

its toll-free telephone number: 1-888-396-5041.

You should not receive a bill from a health care provider for treatment of a covered work-related injury or illness. If

you do receive such a bill, you should contact your employer or the employer’s insurance carrier.

 Wage Loss Benefits

You are entitled to weekly workers’ compensation benefits if you suffer a wage loss for more than seven consecutive

days. These benefits may be claimed as long as a disability and wage loss continue. Generally, the benefit rate is

80% of your after-tax average weekly wage, subject to a maximum rate.

 Vocational Rehabilitation

If you are unable to perform the work that you have done previously, you are entitled to vocational rehabilitation. The

number one goal is your return to work with your employer. If you cannot do this or require assistance in finding a

new job, vocational rehabilitation services can help.

To be completed by the employer

Employer Name

Employer Contact Person and Telephone Number

Workers’ Compensation Insurance Carrier Name

If you have questions, please call the

State of Michigan Workers’ Compensation Agency

Toll-free 1-888-396-5041

Additional information is on the agency’s website at www.michigan.gov/wca.

EMPLOYER: PLEASE POST THIS NOTICE FOR YOUR EMPLOYEES TO SEE!

WC-PUB-005 (5/12)

EMPLOYEES

 Most workers are covered under workers’ compensation from

the date of employment.

 Report all injuries to your supervisor immediately.

 When injured, you can receive wage loss benefits, medical care,

and rehabilitation services.

 A compensable injury is one that has arisen “out of and in the

course of employment.” The work must cause the disability.

 Workers’ compensation is the “exclusive remedy” for work

injuries, meaning that in most cases you cannot sue for other

damages.

 There is a 7-day waiting period for benefit payments. You

will not receive a workers’ compensation check for disability

lasting less than 7 days. However, medical benefits should be

provided from the day of injury. If your wage loss lasts longer

than 7 consecutive days, you are entitled to benefits as of the 8

day. If your wage loss continues for 14 days or longer, you are

entitled to receive payment for that first week of disability.

 In most cases, wage loss benefits are calculated by taking the

average of the highest 39 weeks of the last 52 weeks of gross

wages prior to injury. This is your Average Weekly Wage

(AWW). Generally you should receive 80% of the after-tax value

of your AWW.

 In certain circumstances, the value of discontinued “fringe

benefits” such as the cost of health insurance, employer

contributions to a pension plan, and vacation and holiday pay

may be included in determining the AWW.

 You should be paid your benefit on a weekly basis, and

payments should continue as long as you are disabled and are

suffering a wage loss.

 Your first check is due and payable on the 14

day of disability.

However, a benefit check is not considered “late” until 30 days

after the due date.

 If you have more than one job covered under the Act, the

earnings from Michigan employers are added together to calculate

the AWW.

 You may also be eligible for Family Medical Leave Act (FMLA)

benefits. If you have questions, you should contact the U.S.

Department of Labor.

 Medical Benefits: You are entitled to all reasonable and

necessary medical care including surgical, hospital, and dental

services, as well as crutches, hearing apparatus, chiropractic

treatment, and nursing care. These services are provided

indefinitely as long as there is a need.

 Choosing A Doctor: During the first 28 days of treatment, the

employer has the right to choose the doctor. After that, you are

free to change doctors providing that you notify the employer and

insurance company, preferably in writing. You do not need

authorization from the insurance company or the employer to be

medically treated, as long as the treatment is reasonable and

necessary, and your claim is not in dispute.

 Maintaining Contact: It is extremely important that you maintain

regular contact with your employer throughout the treatment and

recovery period so that they are aware of your progress. Provide

your employer with updated work status reports and discuss early

return to work options.

 Vocational Rehabilitation: If you have a work-related injury or

illness which prevents you from returning to your job and you are

currently receiving workers' compensation benefits, you are

entitled to a maximum of 104 weeks of vocational assistance in

returning to work. Vocational rehabilitation can help you return to

your current job or a new one by identifying interests, skills and

abilities, evaluating accommodations, providing job readiness

assistance, outlining career objectives, and arranging retraining

opportunities. Vocational rehabilitation services create a “win-win”

scenario for employers, carriers, and injured employees, especially

when utilized as an early intervention tool.

EMPLOYERS

 All public and most private employers in Michigan are covered

by workers’ compensation. Every employer subject to the Act

must provide proof of insurance or be approved for self-

insurance to ensure benefits can be paid to its workers should

they become injured.

 Eligible employees are covered under workers’ compensation

from the date of employment.

 There are severe penalties if an employer fails to provide

workers’ compensation coverage.

 Minors: The Act provides that an illegally employed minor is

entitled to double compensation if injured.

 Reporting:

All claims must be reported to your insurance carrier.

 Form WC-100: must be filed with the Workers’ Compensation

Agency and your insurance carrier immediately upon the

disability exceeding 7 consecutive days, death or specific loss. A

copy of this form must also be given to the employee.

 You must ensure that reasonable and necessary medical

treatment is provided promptly.

 You will need to provide a wage history report to the insurance

carrier in order to calculate the correct benefit amount.

 You are encouraged to maintain contact with your employees

while they are off work, and provide appropriate light-duty work

options and accommodations when possible.

INSURANCE COMPANIES

 Prompt and regular payment of benefits is required by law.

 Form WC-701: must be filed with the Workers’ Compensation

Agency (WCA) when wage loss benefits begin, change or

stop.

 Form WC-110: must be filed with the WCA 3 months post-

injury, and every 4 months after, to report on vocational

rehabilitation activity.

 Form WC-107: must be filed with the WCA if a claim is disputed.

 Medical services rendered are subject to the State of Michigan

Health Care Rules and Fee Schedules. Injured employees are not

to be “balance billed” for charges over and above the fee schedule.

 Benefits are not to be stopped for non-cooperation with vocational

rehabilitation, but a hearing can be requested.

WC-PUB-006 (5/12)

orkers’ Com

ensation

enc

Michigan’s workers’ compensation system provides wage replacement, medical treatment, and vocational rehabilitation benefits

to individuals who are injured while at work. Each party in this system has rights and responsibilities that ensure the successful

operation of th

e process.

For more information contact: State of Michigan - Workers’ Compensation Agency

Toll free: 1-888-396-5041 www.michigan.gov/wca

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