Free Michigan Workers' Compensation Application for Reimbursement - Funds Administration - Michigan

FORM 112

APPLICATION FOR REIMBURSEMENT
Michigan Department of Consumer & Industry Services Bureau of Workers' & Unemployment Compensation Funds Administration 7201 W. Saginaw Hwy., Suite 110, Lansing, MI 48917
FUNDS ADMINISTRATION

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FUNDS ADMINISTRATION USE ONLY

1. 2. 3. 4. 5. 6.

Total & Permanent Disability Provision - Section 521 (1) (2) 70% Reimbursement Provision - Section 862 Two Years of Continuous Disability Provision - Section 356 (1) Vocationally Handicapped Provision - Section 925 Dual Employment Provision - Section 372 Silicosis, Dust Disease and Logging Industry Compensation Fund - Section 531

REQUEST NUMBER

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CARRIER FILE NUMBER

COMPLETE THIS SECTION FOR ALL FUNDS
Applications for reimbursement should be submitted every six months unless otherwise indicated.
EMPLOYEE NAME (Last, First, Middle) SOCIAL SECURITY # INJURY DATE BIRTH DATE

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EMPLOYEE ADDRESS (Street No. and Name) (City)

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(State) (Zip)

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(Phone Number)

NAME OF EMPLOYER

EMPLOYER ADDRESS

INSURANCE CO. OR SELF-INSURED EMPLOYER

SERVICE COMPANY OR TPA (If Applicable)

FEDERAL I.D. NUMBER

CONTACT PERSON

TELEPHONE NUMBER

PAYMENT ADDRESS

Tax filing status at time of injury Claimant's Average Weekly Wage Carrier/Employer Present Weekly Compensation Rate $ $

Choose filing status

DEPENDENTS Children

Spouse Birth date

Benefits calculated on a day week IS THERE A THIRD PARTY CLAIM? YES If YES, provide pertinent information on claim.

NO

HAS BASIC BENEFIT CHANGED DURING PERIOD?

YES NO Employment

Date of Benefit Change: Dependency Change (attach verification)

Attach 701 Reason for Change: Unemployment Compensation

Age Reduction Other

Benefit Coordination

HAS EMPLOYEE BEEN GAINFULLY EMPLOYED DURING PERIOD COVERED BY THIS REIMBURSEMENT? YES Attach records confirming employment with evidence of weeks and hours worked, and earnings statement (Provide evidence on value of fringe benefits if applicable) NO Attach information received verifying continuing disability and current activities (1) COMPLETE this section when requesting reimbursement from the Second Injury Fund - TOTAL AND PERMANENT DISABILITY PROVISION: Weekly differential benefits paid on Fund's behalf: thru , weeks at $ =$ thru TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT , weeks at $ =$ $

(2) COMPLETE this section when requesting reimbursement from the Second Injury Fund - 70% REIMBURSEMENT PROVISION: (submit after all appeals are final) (a) Decision by Board of Magistrates ordering payment and order reversing/modifying decision: (b) Confirmation that ALL appeals are final YES NO (c) Copy of all 701s indicating payments (d) Written verification of dependents during appeal period NOTE: Request reimbursement for medical expenses paid under section 862(2) by completing BWC form 271. 70% Benefits Paid on Appeal: thru , weeks at $ =$ thru Total 70% Benefits Paid: Minus: Dollar Value of final award, including interest (if applicable): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT
BWC-112 (Revised 05/02)

,

weeks at $

=$ $ -- $ $

(3) COMPLETE this section when requesting reimbursement from the Second Injury Fund - TWO YEARS OF CONTINUOUS DISABILITY PROVISION Reimbursement due on a quarterly basis Weekly benefit rate paid on Second Injury Fund's behalf: thru thru TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT , , weeks at $ weeks at $ =$ =$ $

(4) COMPLETE this section when requesting reimbursement from the Second Injury Fund - VOCATIONALLY HANDICAPPED PROVISION - Vocational rehabilitation benefits under section 319 are reimbursable from the date of injury thru thru , , weeks at $ weeks at $ =$ =$ $ $ $ $

Total weekly benefits paid on Fund's behalf: Medical expenses paid during period (attach copies of bills and reports): Vocational rehabilitation costs paid during period (attach copies of bills and reports): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT

(5) COMPLETE this section when requesting reimbursement from the Second Injury Fund - DUAL EMPLOYMENT PROVISION - Reimbursement due on a quarterly basis NOTE: (1) (2) (3) Include forms 100 & 701. Attach WAGE RECORDS for all employers. Attach DOCUMENTATION OF DISABILITY, i.e., medical records. Complete only Section II on continuous reimbursement cases, otherwise, complete both.

INSTRUCTION FOR COMPLETION OF SECTION I: (1) 3 or more employers? Use separate sheet to provide information (employer, address, wages) required (2) Carry out apportionment percentages to one hundredths of a percentage (xx.xx% or .xxxx) (3) Average weekly wage with each employer is based upon number of weeks worked at that employer I. Name of Employer: Place of Injury $ Name of Other Employer: Address: Phone: Has there been a return to work with any employer If yes, complete section across: YES NO Employer Employer Employer II. Carrier/Employer Apportionment % of liability: Dual Employment Provision's % of liability: $ 100% (A) ÷ $ (B) = (C) = $ ÷ Total average weekly wages From separate sheet (if applicable): = $ $ $ Date: Date: Date: % (C) % (D)
WAGES NUMBER OF WEEKS USED AVERAGE

÷

=

$

(A)

(B)

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If (D) is less than 20%, the DUAL EMPLOYMENT PROVISION has no liability pursuant to Section 372. Workers' Compensation Benefits paid during period: thru thru , , weeks at $ weeks at $ =$ =$ $ (E) x % (D) = $ (E)

Total weekly benefits paid during this reimbursement period: TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT

(6) COMPLETE this section when requesting reimbursement from the SILICOSIS & DUST DISEASE FUND or LOGGING INDUSTRY COMPENSATION FUND Weekly benefits paid during this period: thru thru thru Total benefits paid during period Minus threshold on first reimbursement only Apportionment percentage due (SDDF only): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT:
SIGNATURE OF AUTHORIZED REPRESENTATIVE TITLE

, , ,

weeks at $ weeks at $ weeks at $

=$ =$ =$ $ x $
DATE SUBMITTED

%

Authority: Completion: Penalty:

Workers Disability Compensation Act R408.46 Voluntary None

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