Free Michigan Workers' Compensation Notice of Dispute (Form BWC-107) - Michigan

Form 107 fill-in instructions

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NOTICE OF DISPUTE
Michigan Department of Labor & Economic Growth Workers' Compensation Agency P O Box 30016, Lansing, MI 48909
1. Social Security No. 2. Date of Injury 3. Employee Name (Last, First, MI)

4. Employee Address (Street No. and Name)

5. City

6. State

7. Zip Code

8. Employer Name

9. Federal ID No.

10. Employer Street Address

11. City

12. State

13. Zip Code

14. Carrier or Self-Insured Name

15. NAIC or Self-Insured No.

16. Zip Code

17. Service Company/TPA Name (if applicable)

18. Service Co./TPA ID No.

19. Zip Code

20. Claim or File No.

21. County of Injury

22. County Code (if known)

23. Reason for Dispute

A. B. C. D. E. F.

Injury not work related Medical treatment not related to injury Further investigation required (please specify below) Additional information required from employee (please specify below) Vocational rehabilitation dispute only (please specify below) Other (please specify below)

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.

Authority: Completion: Penalty:

Workers' Disability Compensation Act, R408.33 (1) Mandatory Workers' Disability Compensation Act, 418.631; 418.801; R408.33

This is to certify that a copy of this form has been mailed or given to the injured employee.
24. Preparer's Name (Please print) 25. Signature 26. Telephone No. 27. Date

NOTICE TO EMPLOYEE
By filing this form, your employer or its workers' compensation insurance company has indicated to the Workers' Compensation Agency that it has a question or a dispute concerning the possible workers' compensation benefits to which you may be entitled. You may or may not agree with the position taken by the employer or insurance company. If you feel that you are not receiving the benefits to which you are entitled, you should discuss this with your employer or a representative of its insurance company. If you have already done that or you are not satisfied with the discussion, you may file a formal application for mediation or hearing. You can obtain the appropriate forms or more information by contacting the Workers' Compensation Agency at our toll-free number of 1-888-396-5041 (if necessary, a TTY device is available at 517-322-5987). Additional information may also be found on our website at www.michigan.gov/wca.

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-107 (Rev. 11/04)

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Form # WC-107 Form Name: Notice of Dispute

Page 1

When Required:

A carrier shall notify the Workers' Compensation Agency on or before the fourteenth day after the employer has notice or knowledge of the alleged injury or death, in all cases where the right of the injured or dependent to compensation is disputed.

Required Fields:

All applicable fields must be completed. U U U Forms will be returned if fields 1-3, 8, and 14 are not completed. You will receive a letter if fields 4 and 23 are not completed. Do not use "Other" as reason for dispute unless absolutely necessary.

Instructions:

Completing the Form:
U U U U U U Select the hand tool from the Acrobat toolbar menu. You can use the hand tool to move the page around so that you can view all areas. Position the hand pointer inside a form field and click. The I-beam pointer allows you to type text. To complete the "red boxes," using your mouse, position the cursor over the applicable box until the pointing finger icon appears and click. Press Tab to accept the field change and go to the next field, or Press Shift + Tab to accept the field change and go to the previous field. Use your mouse to select an area of the form that is not inside a form field before printing your form. To print, be sure to use the printer button on the Acrobat toolbar menu to print the form instead of your web browser's print function. You may need to select the "Print as image" option in the print dialog box to print the completed form. If you wish to print the form only, select "Print Current Page" or "Pages From: 1 To: 1"

U

NOTE: Please complete all date fields with the MM/DD/YYYY format. If you have any comments on this fill-in form, please send them to [email protected]. Please include the keyword "Fill-In Form 107" with your comments.

How to Submit This Form:

U Print the completed form U Sign and make 2 copies ~ Give a copy of the report to the employee ~ Keep a copy for your records ~ Mail the original signed Form 107 to:

Workers' Compensation Agency P O Box 30016 Lansing MI 48909