Free EMPLOYEE'S REPORT OF CLAIM - Michigan

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EMPLOYEE'S REPORT OF CLAIM
Michigan Department of Labor & Economic Growth Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909
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)

6. Employer Name

7. Employee Street Address

8. Employer Street Address

9. Employee City

10. State

11. ZIP Code

12. Employer City

13. State

14. ZIP Code

15. Describe the type of injury and explain how it happened. (If a medical report is available, please attach a copy.)

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

Yes

No

17. Last Day Worked

If yes, please attach a copy of medical bill(s) if available.
18. Have you gone back to work?

Yes

No

19. Was the injury reported to your employer?

Yes

No

If yes, date of return __________/__________/__________

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

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-117 (Rev. 9/05)

Authority: Workers' Disability Compensation Act, 408.31(4) Completion: Voluntary Penalty: None