Free APPLICATION FOR REIMBURSEMENT FROM THE - Michigan

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APPLICATION FOR REIMBURSEMENT FROM THE COMPENSATION SUPPLEMENT FUND
Michigan Department of Labor & Economic Growth Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 Initial (For Quarter) Corrected

Employer Name (Type or print)
Employee Name (Last, First, MI) Employee Street Address Social Security Number Date of Injury (MM-DD-YYYY) City

Carrier File No.

State

Zip Code

Average Weekly Wage on Date of Injury

Date of Birth (MM-DD-YYYY) Carrier I.D. Number

Name of Insurance Company or Self-Insured Carrier Address (Street) Federal Employer I.D. Number City

State

Zip Code

Reimbursement Requested For:

Weekly Comp. Rate on Jan. 1, 1982 Quarter ___________ Calendar Year _____________

Compensation Paid Date from
(MM-DD-YYYY)

Date to
(MM-DD-YYYY)

Weeks

Days

Supplement Percentage

Weekly Second Injury Fund Differential Benefits Paid

Weekly Compensation Supplement

Total Supplement Paid

Total Reimbursement Requested Date of death Date of redemption Return to work Other Comments:

$ ___________

Signature of Authorized Representative (In Ink)

Name of Person to Whom Correspondence Should Be Sent (Please Print)

Date of This Report

Address

Telephone Number

NOTICE: The initial form WC-114 must be filed within three (3) months after the end of the calendar quarter in which benefits are first paid. No subsequent reimbursements will be allowed for a period which is more than one (1) year prior to the filing date of the Form WC-114.

Authority: Completion: Penalty:

Workers' Disability Compensation Act, 418.352; R408.32(2)(3) Mandatory Workers' Disability Compensation Act, 418.631; 418.801

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-114 (Rev. 8/05)