Free CARRIER'S RESPONSE - Michigan

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CARRIER'S RESPONSE
Michigan Department of Labor & Economic Growth Workers' Compensation Agency PO Box 30016, Lansing, MI 48909
Social Security Number Date of Birth Employee Name

Employee Address (Street No. and Name)

Employee City

State

Zip Code

Date(s) of Injury

Insurance Company/TPA Claim Number

Employer

Insurance Company or TPA (If self-insured)

Employer Address (Street No. and Name)

Insurance Company Address (Street No. and Name)

City

State

Zip Code

City

State

Zip Code

Federal ID Number

NAIC or Self-Insurance Number

1. Do you dispute that the injury or disability is work related? 2. Do you dispute that the claimant is disabled? 3. List reasons supporting your position in the space provided.

Yes Yes

No No

4. Have you had the claimant medically examined in connection with this claim? If yes, give name and address of individual who performed the examination.

Yes

No

5. Do you certify that to the best of your knowledge all existing medical records of the carrier or employer contained in your file that are relevant to this claim have been furnished to the claimant and/or the claimant's attorney? Yes No
Claims person/attorney to whom correspondence should be sent Attorney ID Number (If applicable)

Claims office/attorney address

Telephone No. (Include area code)

Preparer Signature

Date

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-251 (8/05)

Authority: Completion:

Penalty:

Workers' Disability Compensation Act, Section 418.222 This form is to be submitted by the carrier within thirty (30) days after the carrier's receipt of a completed Application for Mediation or Hearing. Failure to complete shall prohibit that party from proceeding.