Free SUPPLEMENTAL REPORT OF FATAL INJURY - Michigan

Print

Reset

SUPPLEMENTAL REPORT OF FATAL INJURY
Michigan Department of Labor & Economic Growth 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 4. Name (Last, First, Middle Initial) 5. Street Address 6. City 7. State 8. ZIP Code 2. Date of Injury 3. Date of Death

II. EMPLOYER DATA
9. Employer Name 11. Street Address 12. City 10. Federal I.D. Number 13. State 14. ZIP Code

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

$
III. DEPENDENTS OF EMPLOYEE
16. 17. 18. 19.

Name

Date of Birth

Relationship to Deceased
(Spouse, Child, or Other - Please Specify Other)

Extent of Dependency
(Total/Partial)

20. Employer's Signature

21. Title

22. Date

The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. WC-106 (7/05)

Authority: Workers' Disability Compensation Act, R408.31(3) Completion: Mandatory Penalty: Workers' Disability Compensation Act 418.631