Free MULTIPLE CARRIER REDEMPTION FORM - Michigan


File Size: 50.0 kB
Pages: 1
Date: April 19, 2007
File Format: PDF
State: Michigan
Category: Workers Compensation
Author: Consumer & Industry Services
Word Count: 197 Words, 1,464 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.michigan.gov/documents/wca/wca_WC-113A_fillin_193619_7.pdf

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MULTIPLE CARRIER REDEMPTION FORM
Michigan Department of Labor & Economic Growth Workers' Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909
Plaintiff Social Security Number

CARRIER 1
Employer Employer

CARRIER 2

Insurance Company

Insurance Company

Date(s) of Injury

Date(s) of Injury

CARRIER 3
Employer Employer

CARRIER 4

Insurance Company

Insurance Company

Date(s) of Injury

Date(s) of Injury

CARRIER 1 1. Attorney Fees 2. Attorney Expenses 3. Direct Payments (Medical) 4. Direct Payments (Non-medical) 5. Plaintiff's Redemption Fee 6. Balance to Plaintiff 7. Allocated to Medical (Not included in 3 above) 8. Total Payment 9. Cost of Annuity (If applicable)

CARRIER 2

CARRIER 3

CARRIER 4

TOTAL

Carrier # _______ to remit defendant's statutory redemption fee of $100.00 directly to State of Michigan. Carrier # _______ to complete the payment of weekly compensation of $ _____________ per week through ____________________.
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-113A (8/05)

Authority: Completion: Penalty:

Workers' Disability Compensation Act, 418.835; 418.836; 418.837 Voluntary None