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
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
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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
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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)
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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
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.
Yes No
17.
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
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)
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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
th
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
th
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)
W
orkers’ Com
p
ensation
A
g
enc
y
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