Free Need to Know How to Complete a Form 701? - Michigan

GENERAL INFORMATION - FORM 701

The Form WC-701 (hereafter referred to as Form 701) is used to report to the Agency payment of weekly compensation benefits made to the employee. Attorney fees, rehabilitation costs, medical expenses, etc. should not be reported on the form. Burial expenses must be reported by the employer on Form WC-106 or a receipt of payment will be requested. The filing number should always be #1 the first time the Form 701 is submitted for a claim, and then increase sequentially for subsequent filings. It is critical that all subsequent filings contain the exact SSN and DOI that was reported on the first filing. If this information was previously reported in error, the correction(s) should be clearly marked on the form. Friend of the Court payments should not be reported to the Agency. All Agency orders have a nine digit number written in the upper right hand corner consisting of the mailed date and a three digit sequential number. All Form 701's that are filed pursuant to an award (basis of payment anything other than "A") should have the order number included in the space provided below section D. Redemption amounts should not be reported on a Form 701. If the redemption involves a claim which is in payment status, the system will automatically close out the weekly payments assuming that the weekly rate, date of injury and carrier listed on the redemption order match the information on the latest Form 701. If not, a Form 701 must be filed closing out the weekly payments. A Form 701 must also be filed if partial benefits are being paid at the time of the redemption. Lump sum advance payment amounts should not be reported on a Form 701. If the advance payment order results in a reduction or termination of the weekly rate, a Form 701 must be filed showing the rate change or termination. In February of each year, the Agency runs a program which closes all open paying claims as of December 31st and reopens them on January 1st. Once that is done, an Open Claim Validation Report is sent to each carrier or service company/TPA listing all claims that closed and reopened as well as those that could not be closed because of an error. This report should be used to verify that all claims on the report are still in open payment status and that the rate is correct. If not, the appropriate Form 701's should be filed. If partial benefits are being paid, the employee worked less than a 5 day work week, or the compensation rate is in error, a Form 701 must be filed. Form 701's which are filed to report payment of accrued benefits as a result of an order or agreement which cover multiple benefit periods should have the Report of Accrued Benefits worksheet (or a similar format) attached and include all available information: basis, benefit type, special payment, weekly rate, from and through dates and total amounts paid for each payment period. Interest payments, when applicable, should be reported on a separate line from the accrued benefit period(s) and include the special payment code, through date and total interest payment only.

Page 1 of 5

FILING INSTRUCTIONS FOR FORM 701 PART A This section must be completed when filing the Form 701. Extreme care should be taken to ensure that all subsequent filings contain the same SSN and DOI. #1. #2. #3. #4. #5. #6-9. #10. #11. #12. Social Security Number: 9 digit numeric. Date of Injury: Must be complete date (MM/DD/YY). Employee Name: Employee's last name, first name and middle initial. Date of Birth: Must be complete date (MM/DD/YY). Date of Death: If employee is deceased, enter complete date (MM/DD/YY). Employee Address: Complete mailing address of employee. Employer Name: Enter complete business name of employer (DBA, etc.). Federal ID Number: Enter 9 digit Federal ID number used by the employer listed in #10. Injury Location Code: This should be left blank. It is an internal three digit location code that is assigned and used by agency staff only. Employer Address: Complete address of employer, including number, street, city, state and zip code. Carrier or Self-Insured Name: Enter complete name of carrier or self-insured employer. A service company/TPA name should not be reported in this field. NAIC or Self-Insured Number: Carriers should report their 5 digit NAIC number and 4 digit group code, and self-insureds should report their 8 digit self-insured ID number. Service Company/TPA Name: Enter name of service company/TPA handling claim, if applicable. Service Company/TPA Number: The 3 digit service company/TPA ID number assigned by the Agency must be reported if a service company/TPA name is present in #19. Zip Code of Issuing Office: Zip code of carrier, self-insured employer or service company/TPA filing the form. The zip code will be used in conjunction with the carrier or service company/TPA ID to identify the mailing address of the appropriate office where correspondence should be sent. Carrier or Self-Insured Claim Number: Submitter's claim or file number, if applicable. This number will appear on all system generated correspondence. Date Carrier Received Notice of Injury: The date carrier received notice of injury. This information is required on all voluntary payment cases to determine promptness of payment. Date First Payment Made: The date the first check was sent out on this claim. This date is required on all voluntary payment cases to determine promptness of payment. If the employer is continuing to pay wages while the compensability issue is being resolved or benefits are being coordinated under a wage continuation plan, the date first payment made should be the same as the from date in Part D.

#13-16. #17.

#18.

#19. #20.

#21.

#22.

#23.

#24.

Page 2 of 5

PART B This section must be completed when filing the Form 701. #25. Nature of Injury: Provide a brief description of the injury or disease. If desired, the codes from the attached list may be entered in addition to the description. Part of Body: Provide a brief description of the part of body affected by the injury or disease. If desired, the codes from the attached list may be entered in addition to the description. Average Weekly Wage: Total weekly wages from place of injury, excluding fringes. Discontinued Fringes: Weekly fringe benefits that are not continuing during the disability period. Second Employer AWW: Total wages from second employer, if applicable. Second Employer Discontinued Fringes: Discontinued fringes from second employer, if applicable. Tax Filing Status on Date of Injury: Employee's tax filing status at the time of injury using the Federal income tax eligibility criteria. The status does not change during the life of the claim. Last Day Worked: Last day preceding the current disability period in which the employee received full wages. Number of Days in Work Week: Number of days the employee is regularly scheduled to work per week. If the employee works less than a 5 day week, we are unable to calculate the total amount paid. Therefore, if any of these claims are in open payment status at the end of the year, a Form 701 must be filed reporting the amount of compensation paid during the year. All payments made for dates of injury on and after May 11, 1999 must be calculated on a 7 day work week per Rule 408.31a. Number of Dependents: Number of dependents, not including the employee. PART C This section must be completed when filing the Form 701. The information should always pertain to the latest payment period reported on the form. #35. A. B. Reason for Filing: The appropriate code must be entered on all filings: Used whenever benefits are commencing and continuing. Complete the Basis of Payment, Benefit Type, Special Payment (if applicable), Weekly Rate, and From Date. Used whenever there is a change in the current rate and benefits are continuing. Complete the entire first line (except for the termination reason) in order to close out the old rate, as well as the first half of the second line in order to report the new Total Weekly Rate and From Date. If benefits covered more than one calendar year, the From Date on the first line should always be January 1 of the current year. When benefits are changing from partial to total, a wage statement showing the calculation of partial payments must also be attached to the Form 701. Used whenever benefits that were previously reported are now being terminated. Complete the entire first line showing the total payments made for the current calendar year only. Used whenever benefits that have never been previously reported are both commencing and terminating. Complete the entire first line showing the total payments that were made. Used whenever the rate is staying the same but reimbursements are now being received from either the Silicosis, Dust Disease and Logging Industry Compensation Fund or the Vocationally Handicapped Provisions of the Second Injury Fund. Complete the entire first line to close out the rate and payment period (if payments covered multiple calendar years, use January 1 of the current calendar year) for which the carrier is responsible, as well as the first half of the second line in order to give us the new From Date for which reimbursement takes effect.

#26.

#27. #28. #29. #30. #31.

#32.

#33.

#34.

C. D. E.

Page 3 of 5

F.

G. H.

I. #36.

Used whenever a claim that had previously been in payment status is now reopening and benefits are continuing. Complete the Basis of Payment, Benefit Type, Special Payment (if applicable), Weekly Rate, and From Date. Used whenever benefits are both commencing and terminating on a claim that had previously been in payment status. Complete the entire first line showing the total payments that were made. Used to report the amount of partial benefits that were paid on all claims which are in partial benefit status as of 12/31. A wage statement should also be attached. This code should also be used when reporting yearly payments on any claim still in payment status at the end of the year in which the employee worked less than a 5 day work week. Complete the entire first line (except for the termination reason) in order to report the partial payments that were made during the previous calendar year (show the through date as close to 12/31 as possible) as well as the first half of the second line using a From Date one day after the Through Date. A partial payment worksheet must also be attached to the form. Used whenever information was improperly reported on a previous Form 701. Weekly Compensation Base Rate: The base rate which is owed prior to taking into account any adjustment(s) specified in item 37. Weekly Adjustments to Base Rate: This item should always be completed when the base rate in item 36 does not match the "total weekly rate" in Part D. Record the appropriate code(s) and weekly dollar amount(s). If the code is equal to A-G (coordination of benefits), the appropriate section in Part E should also be completed on the back of the form. If the code is equal to "J" or "K", the order number must also be entered in the space provided below Part D. Weekly Amount Being Reimbursed by a Fund: Indicate the appropriate code(s) and weekly dollar amount(s) being reimbursed by the Silicosis, Dust Disease and Logging Industry Compensation Fund or the Vocationally Handicapped Provisions of the Second Injury Fund. Do not record any Compensation Supplement Fund payments (adjustment code of "I") or Second Injury differential benefits (adjustment code of "L"). These amounts should be reported in #37. Also, do not report any reimbursements received as a result of the 70% or Dual Employment provisions. This information will be provided to us by the Second Injury Fund. PART D

#37.

#38.

This section must be completed as follows when filing the Form 701 on a claim: BASIS OF PAYMENT Indicate the appropriate code from the back of the Form 701. When a claim is being paid pursuant to any type of order, including a Voluntary Payment Form (WC-115), include the order number in the space provided below Part D. BENEFIT TYPE Indicate the appropriate code from the back of the Form 701. This information is always necessary unless a Special Payment type code is present. Also, the first filing reporting a specific loss benefit type ("C") should include a copy of the amputation chart signed by the physician or affidavit of vision loss, whichever applies. The number of loss weeks and effective date of loss should be completed below Part D. When the benefit type is "D" (Permanent Total), there must be an adjustment code of "L" (SIF differential benefits) and an amount reported in #37. SPECIAL PAYMENT This code is only necessary when the payment period is pursuant to an award. When interest is being reported, the through date should reflect the date that the accrued benefits were paid.

Page 4 of 5

TOTAL WEEKLY RATE This should reflect the amount the employee actually receives per week and should equal the Base Rate in line 36 plus or minus any adjustments reported in line 37. The weekly rate should be left blank when the benefit type is "B" (partial wage loss). FROM DATE The effective date for the payment period. Do not include the waiting week for the initial disability period unless benefits were paid for those dates. If benefits covered more than one calendar year, the from date should be January 1 of the current year. This field may be left blank when special payment code is "B" (interest). THROUGH DATE The ending date (current calendar year only) of the rate/benefit type or the payment termination date, whichever applies. If a special payment code of "B" (interest) is being reported, the through date should reflect the date accrued benefits were paid. TOTAL AMOUNT PAID Indicate the total amount paid to the employee for the payment period. This field is required whenever a through date is present. If an overpayment was made but not recouped, the amount actually paid to the employee should be reflected. If partial benefits are being terminated, the total amount paid must be entered in Part D. YEAR PAID Indicate the year the total amount was paid for the payment period reported on the form. TERMINATION REASON When the reason for filing is "C", "D" or "G" (all terminating benefits), the termination reason code is required. When the termination reason is "B" (recovered from disability), a medical report must be attached. Whenever partial benefits are being terminated, a partial payment worksheet must be attached. If the termination reason is "E" (claimant deceased), a death certificate must be attached. BELOW PART D ORDER # If payments are being made pursuant to an award or voluntary payment agreement (Form WC-115), provide the 9 digit order number that is located in the upper right hand corner of all orders mailed out by the Agency. SPECIFIC LOSS If the benefit type code is "C" (specific loss), enter the exact number of specific loss weeks as well as the effective date of the loss. An amputation chart (WC-728) or vision affidavit, whichever is applicable, should also be attached. "OTHER" FILING CODES If any of the codes used on the form refer to "other", the exact reason must be listed here.

#39. #40. #41.

Authorized Signature: The signature of an individual authorized to file this form. Person Handling Claim: Print the name of the individual who is handling the claim. Telephone Number: Enter the telephone number, including extension, of the individual listed in #40 who is handling the claim. Date: Enter the date the form was prepared.

#42.

Page 5 of 5

Please complete all date fields with the MM/DD/YYYY format.

Print

Reset Form

REPORT OF ACCRUED BENEFITS
SS# ______________________ Order # ____________________ Benefit Type Special Payment Adjusted Rate DOI ______________ Employee Name _____________________________ Year Paid _____________ Total Variable Rate Factors
Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______

Basis Payment Code __________ From Through

Basis of Payment A = Voluntary Payment B = Open Award C = Closed Award D = Stipulated Award E = Compromise F = Form 115 Voluntary Pay Weekly Adjustments to Base Rate A = Wage Continuation Offset B = Social Security Coordination C = Pension Offset D = Unemployment Offset E = Disability Insurance Offset F = Self-Insurance Offset G = Other Benefit Coordination H = Age 65 Reduction I = Compensation Supplement

Benefit Type A = General Disability B = Partial Wage Loss C = Specific Loss D = Permanent Total E = Death F = Other

Special Payment A = Accrued Benefits B = Interest C = 30% Appeal Adjustment D = Other

J= K= L= M= N= O= P= Q=

Advance Payment 30% Appeal Adjustment SIF Differential Benefits Double Compensation Third-Party Offset 2-Years Continuous Disability Recoupment of Overpayment Other

NATURE OF INJURY CODES
Code 300 Abrasions 183 Abscess Description Code Description 200 Electric shock, electrocution 274 Emphysema Environmental heat (does not include 240 sunburn) 260 Epicondylitis 995 184 530 210 220 260 276 276 273 230 991 991 240 320 330 250 190 159 991 150 572 274 294 293 530 260 170 551 Epilepsy Erythema, toxic Eye diseases Fracture Freezing (includes frostbite) Ganglion cyst Gastro-enteritis Gastro-intestinal diseases Hay fever, toxic (systemic poisoning) Hearing loss or impairment Heart attack Heart conditions Heatstroke Hemorrhoids (circulatory system) Hepatitis (serum & infective) Hernia, rupture Herniated disc Herpes Hypertension Infective or parasitic disease, unspecified Influenza Influenza, toxic (systemic poisoning) Ionizing radiation - Isotopes Ionizing radiation - X-Ray Iritis Joints, inflammation or irritation Laceration Leukemia

281 Aluminosis - aluminum exposure 100 Amputation or enucleation (loss of an eye) 272 282 152 540 283 110 572 274 552 590 300 272 183 572 274 153 160 130 120 260 284 551 183 562 310 183 561 561 510 159 276 520 140 154 530 160 160 170 950 Anemia Anthracosis - coal dust Anthrax Anxiety Asbestosis - asbestos fibers Asphyxia Asthma Asthma, toxic (systemic poisoning) Benign and unspecified tumor Bites, human and non-toxic animal Blisters Blood diseases (includes purpura) Boils Bronchitis Bronchitis, toxic (systemic poisoning) Brucellosis Bruise Burn (chemical) Burn or scald (heat) Bursitis Byssinosis - cotton dust Cancer Carbuncles Carpal tunnel Cartilage, torn Cellulitis Central nervous system Cerebral palsy Cerebrovascular & other circulatory conditions Chicken pox Colitis Complications peculiar to medical care (toxic or non-toxic) Concussion (brain, cerebral) Conjunctivitis (non-toxic) Conjunctivitis, chemical Contusion Crush Cut Damage to prosthetic devices (includes eyeglasses, false teeth, etc.)

184 Lichen 530 Loss of vision 551 Malignant tumor 159 Measles 540 292 561 995 400 159 Mental disorders Microwave, radiation effects Migraine Miscarriage Multiple injuries Mumps

260 Muscles, inflammation or irritation 562 Nerves and peripheral ganglia (includes Bell's Palsy)

540 Depression

Page 1 of 2

NATURE OF INJURY CODES
Code Description Code Description

540 Derangement, internal 185 Dermatitis, allergenic or contact 180 Dermatitis, unspecified 190 Dislocation & dislocated disc 110 Drowning 151 Dysentery, amebiasis Effects of changes in atmospheric 500 pressure (equilibrium) Other pneumoconiosis and related 287 diseases 184 Other skin conditions 279 Other toxic effects on one system only 190 Pinched nerve (back only) 310 Pinched nerve (other than back) Pneumoconiosis & related diseases, 280 unspecified 289 Pneumoconiosis with tuberculosis 572 Pneumonia 274 Pneumonia, toxic (systemic poisoning) 274 Pneumonitis 280 Pneumothorax 270 Poisoning, systemic, unspecified 271 Poisoning, toxic material 183 184 170 290 570 581 273 310 300 285 286 Primary Infections of the skin Pruritus Puncture Radiation effects, unspecified Respiratory System, conditions of, unspecified Rhinitis Rhinitis, toxic (systemic poisoning) Rotator cuff tear Scratches Siderosis - metallic dust Silicosis - silica dust

560 Nervous system, conditions of, unspecified 540 Neurosis 900 No injury or illness 999 Nonclassifiable Occupational disease (not elsewhere 990 classified) 159 Other infective diseases 995 Other injury, not elsewhere classified 273 Sinusitis, toxic (systemic poisoning) 189 170 273 310 Skin conditions, unspecified Sliver Smoke inhalation Sprains

310 Strains 110 540 510 110 291 240 580 260 260 260 156 Strangulation Stress Stroke Suffocation Sunburn, etc. (non-ionizing radiation) Sunstroke Symptoms & ill-defined conditions (e.g., fainting) Tendinitis Tendons, inflammation or irritation Tenosynovitis, stenosing Tetanus

275 Toxic hepatitis 157 550 571 510 295 310 Tuberculosis Tumor, neoplasm, unspecified Upper respiratory Varicose veins Welder's flash (eyes only) Whiplash

* When two codes are listed, the first represents nature of injury and the second is part of body

Page 2 of 2

PART OF BODY CODES
Code 410 520 310 318 319 801 420 311 820 800 830 110 430 440 200 141 450 810 121 124 120 313 840 130 148 149 140 511 515 340 Description Abdomen (include internal organs); Hernia, inguinal Ankle Arm(s), above wrist, unspecified Arm, multiple Arm, not elsewhere classified Arteries; Blood; Circulatory system; Heart; Veins Back (include back muscles); Coccyx; Lumbar; Sacrum; Spinal cord; Spine Biceps; Humerus; Triceps; Upper arm Bladder; Excretory system; Intestines; Kidneys Body system, unspecified Bones; Joints; Muscles; Musculo-skeletal system; Tendons Brain; Concussion Breastbone; Chest (internal organs); Pectorals; Ribs; Sternum; Thorax Buttocks; Hips; Pelvic organs; Pelvis Cervical; Neck Cheek; Chin; Jaw; Mandible Clavicle; Deltoid; Scapula; Shoulder(s) Digestive system Ear(s), external Ear(s), internal Ear(s), unspecified Elbow; Olecranon Epilepsy; Nervous system Eye(s); Eyelid; Optic nerves; Vision Face, multiple parts Face, not elsewhere classified; Forehead Face, unspecified Femur; Thigh Fibula; Lower leg; Tibia Finger(s) Code 350 530 315 397 330 198 100 513 510 518 519 144 598 500 850 700 146 999 880 150 160 147 540 550 498 400 398 300 320 Description Fingertip(s) Foot (not ankle or toe); Metatarsal Forearm; Radius; Ulna Hand & Finger(s) Hand (not wrist or fingers); Metacarpal Head, multiple Head, unspecified Knee; Patella Leg(s) (above ankle), unspecified Leg, multiple Leg, not elsewhere classified Lips; Mouth (includes sense of taste, excludes teeth); Throat; Tongue Lower extremities, multiple Lower extremities, unspecified Lungs; Respiratory system Multiple parts (use when more than one major body part has been affected) Nasal passages; Nose (includes sense of smell); Sinus Nonclassifiable (insufficient information to identify affected part) Other body systems Scalp Skull Teeth Toe(s) Toetip(s) Trunk, multiple Trunk, unspecified Upper extremities, multiple Upper extremities, unspecified Wrist

List of Form 701 Examples

Example # Filing Reason Description 1 2 3 4 5 6 7 8 9 10 11 A A B C D F G H A D B Commencing Benefits (No adjustments to base rate) Commencing Benefits (With adjustments to base rate) Change in Weekly Rate due to decrease in dependents Terminating Benefits Commencing & Terminating Benefits Reopening Claim Reopening & Closing Claim Yearly Report of Partial Payments Commencing Benefits as the result of an Open Award Reporting of a Compromised Payment Change in Weekly Rate due to reporting of P & T differential benefits

EXAMPLE #1 FILING REASON "A" ­ COMMENCING BENEFITS (NO ADJUSTMENTS TO BASE RATE)

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
A

Ankle (520) 0.00
2/1/2007

7

3

310.14

A

A

$310.14

2/2/2007

Bill Parker

(517) 999-9999

2/12/2007

EXAMPLE #2 FILING REASON "A" ­ COMMENCING BENEFITS (WITH ADJUSTMENTS TO BASE RATE)

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
A A 387.68

Ankle (520) 0.00
2/1/2007

7

3

310.14

A

A

$0.00

2/2/2007

Bill Parker

(517) 999-9999

2/12/2007

$450.00 $310.14
$387.68

100% $387.68

EXAMPLE #3 FILING REASON "B" ­ CHANGE IN WEEKLY RATE

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
A

Ankle (520) 0.00
2/1/2007

7

3

310.14

A

A

$310.14

2/2/2007

Bill Parker

(517) 999-9999

2/12/2007

2

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
B

Ankle (520) 0.00
2/1/2007

7

2

303.95

A
A

A

$310.14
$303.95

2/2/2007 3/13/2007

3/12/2007

$1,727.92 2007

A

Bill Parker

(517) 999-9999

3/15/2007

EXAMPLE #4 FILING REASON "C" ­ TERMINATING BENEFITS

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
A

Ankle (520) 0.00
2/1/2007

7

3

310.14

A

A

$310.14

2/2/2007

Bill Parker

(517) 999-9999

2/12/2007

2

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
C

Ankle (520) 0.00
4/4/2007

7

3

310.14

A

A

$310.14

2/2/2007

4/6/2007

$2,835.57 2007

A

Bill Parker

(517) 999-9999

4/12/2007

EXAMPLE #5 FILING REASON "D" ­ COMMENCING & TERMINATING BENEFITS

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Burn (120) 450.00 C
D

Arm (310) 0.00
2/1/2007

7

3

310.14

A

A

$310.14

2/2/2007

3/12/2007

$1,727.92 2007

A

Bill Parker

(517) 999-9999

3/13/2007

EXAMPLE #6 FILING REASON "F" ­ REOPENING CLAIM

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
D

Ankle (520)

0.00
2/1/2007

7

3

310.14

A

A

$310.14

2/2/2007

3/12/2007

$1,727.92 2007

A

Bill Parker

(517) 999-9999

3/13/2007

2

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
F

Ankle (520) 0.00
4/4/2007

7

3

310.14

A

A

$310.14

4/5/2007

Bill Parker

(517) 999-9999

4/12/2007

EXAMPLE #7 FILING REASON "G" ­ REOPENING & CLOSING CLAIM

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C
D

Ankle (520) 0.00 2/1/2007

7

3

310.14

A

A

$310.14

2/2/2007

3/12/2007

$1,727.92 2007

A

Bill Parker

(517) 999-9999

3/13/2007

2

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/1/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/3/2007

2/7/2007

Sprain (310) 450.00 C 0.00
4/4/2007

Ankle (520)

7

3

G

310.14

A

A

$310.14

4/5/2007

4/20/2007

$708.89

2007

A

Bill Parker

(517) 999-9999

4/22/2007

EXAMPLE #8 FILING REASON "H" ­ YEARLY REPORT OF PARTIAL PAYMENTS

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

11/4/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

11/8/2007

11/11/2007

Hearing Loss (230) 450.00 C
A

Ears (124) 0.00
11/4/2007

7

3

310.14

A

B

11/5/2007

Bill Parker

(517) 999-9999

11/14/2007

2

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

11/4/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

11/8/2007

11/11/2007

Hearing Loss (230) 450.00 C
H

Ears (124) 0.00
11/4/2007

7

3

310.14

A
A

B

11/5/2007 12/31/2007

12/30/2007

$188.03

2007

B

Bill Parker

(517) 999-9999

1/2/2008

Print Date: 09/03/2008 Print Time: 11:49:20

Workers' Compensation Agency Verification of Monetary Information Partial Benefit Rates
For Year: 2007

Page: 1 Version: 9.0

File Name: John R. Doe Prior to Injury Year of Injury: Gross Weekly Wage: Discontinued Fringes: Nbr of Dependents: Tax Class: 2007 $450.00 $0.00 3 3

Last Update: 09/03/2008

11:48:20

80 Percent Rate

$310.14 (Including fringes)

After Injury

Begin Date 11/05/2007 11/12/2007 11/19/2007 11/26/2007 12/03/2007 12/10/2007 12/17/2007 12/24/2007

End Date 11/11/2007 11/18/2007 11/25/2007 12/02/2007 12/09/2007 12/16/2007 12/23/2007 12/30/2007

Year Paid 2007 2007 2007 2007 2007 2007 2007 2007

80% Rate Before Injury $310.14 $310.14 $310.14 $310.14 $310.14 $310.14 $310.14 $310.14

Wages Received 400.00 386.00 450.00 410.00 320.00 425.00 450.00 450.00

80% Rate After Injury 279.81 271.25 310.14 285.92 230.59 295.10 310.14 310.14

Partial Rate 30.33 38.89 0.00 24.22 79.55 15.04 0.00 0.00 $188.03

Grand Totals: Number of Weeks: 8

EXAMPLE #9 BASIS OF PAYMENT "B" ­ OPEN AWARD BENEFITS ORDERED @ $345.98 PER WEEK BEGINNING ON 3/12/06 ACCRUED BENEFITS PAID ON 5/8/07

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

3/11/2006

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

3/13/2006

5/8/2007

Heart Attack (991) 610.00 C
A

Heart (801) 0.00
3/11/2006

7

2

426.01

B

A

$426.01

5/9/2007

042007008

Bill Parker

(517) 999-9999

5/10/2007

Print Date: 09/03/2008 Print Time: 12:08:08

Workers' Compensation Agency Verification of Monetary Information Accrued Payment & Interest

Version: 9.0

Begin Date 03/12/2006

End Date 05/08/2007

Paid Date 05/08/2007

Comp Rate $345.98

Days Total Rem Worked Weeks Days 7 60 60 3 3

Total Comp $20,907.08 $20,907.08

Total Interest $1,174.43 $1,174.43

Total Comp & Interest $22,081.51 $22,081.51

Grand Totals

EXAMPLE #10 BASIS OF PAYMENT "E" ­ COMPROMISE (RATE & TERMINATION REASON NOT REQUIRED)

1

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

2/5/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

2/10/2007

5/2/2007

Inflammation (260) 0.00

Hip (440)

7
D

E

A

$1,500.00 2007

042807010

Bill Parker

(517) 999-9999

5/12/2007

EXAMPLE #11 BENEFIT TYPE "D" ­ PERMANENT TOTAL

2

111-22-3333 123 Elm Street Smith's Auto Repair 3310 Baker Street

10/15/2007

Doe, John R. Lansing

9/4/1950 MI 38-1111111 Lansing MI 999999999 48915 48910

United States Insurance Company

48912

D12345-1

10/18/2007

10/21/2007

Industrial Loss of Use 226.00 D
B L 43.63

Legs (510) 0.00
10/15/2007

7

2

161.38

B
B

A

$161.38
$205.01

10/16/2007 1/1/2008

12/31/2007

$1,775.18 2007

D

Bill Parker

(517) 999-9999

1/5/2008