Free VOLUNTARY PAYMENT FORM - Michigan

Print

Reset

(Personal Service)

(Mailed)

VOLUNTARY PAYMENT FORM
Michigan Department of Labor & Economic Growth Workers' Compensation Agency/Board of Magistrates P.O. Box 30016, Lansing, MI 48909

_____ Day of __________ 20

Magistrate/Mediator (Please print)
Plaintiff Defendant

Plaintiff's Social Security Number

Date of Injury

The plaintiff and defendant agree that the plaintiff's Application for Mediation or Hearing is withdrawn. The defendant agrees to pay benefits on a voluntary basis in accordance with the following:
a. Weekly benefit rate Less benefits to be coordinated Subtotal Plus supplemental benefit TOTAL Benefits to be paid for the period from b. c. d. e. f. Medical expenses to be paid? If yes, to whom? Reimbursement to group carrier? Atty. fee to be charged Yes No Amount $_____________________ Percent ______% Yes $____________________ $____________________ $____________________ $____________________ $____________________ ____________________ through _________________ No

Atty. Fed. I.D.# _____________________________ Amount of interest to be paid $____________________ Additional agreements (attach additional sheets if necessary)

Neither the payment of compensation nor the accepting of same by the employee or his/her dependents shall be considered as a determination of the rights of the parties under this Act. All benefits become due and payable on the day of personal service or the mailing date.

Plaintiff

Defendant

Representative of Plaintiff

Representative of Defendant

Date

Magistrate/Mediator
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.

Authority: Workers' Disability Compensation Act 418.222; 418.223; 418.847; R408.33(2)(b) Completion: Voluntary Penalty: None

WC-115 (Rev. 05/05)