Skip Navigation
Worker's Compensation Official Web Site for the State of Michigan Home
close print view
Claims Forms

• WC-100 (2/13) - Employer's Basic Report of Injury (fill-in form) PDF icon

• WC-106 (10/11) - Supplemental Report of Fatal Injury (fill-in form) PDF icon

• WC-107 (2/13) - Notice of Dispute (fill-in form) PDF icon

• WC-108 (11/11) - Application for Advance Payment (fill-in form) PDF icon

• WC-114 (11/11) - Application for Reimbursement from the Compensation Supplement Fund (fill-in form) PDF icon

• WC-117 (4/13) - Employee's Report of Claim (fill-in form) PDF icon

• WC-701 (2/13) - Notice of Compensation Payments (fill-in form)

• WC-701 (7/12) - Filing Codes PDF icon

• Need to Know How to Complete a Form 701? PDF icon

• WC-728 (12/11) - Amputation Chart (fill-in form) PDF icon

Funds Administration Forms

• WC-FA112(1/14) Application for Reimbursement (from the Funds Administration) (fill-in form) PDF icon

• WC-271 (1/14) Application for Reimbursement from the Medical Benefits Fund (fill-in form) PDF icon

Health Care Services Forms

• WC-104B (9/13) - Health Care Services Application for Mediation or Hearing (fill-in form) PDF icon

• WC-117H (1/12) Provider's Report of Claim & Request for Medical Payment PDF icon

• WC-590 Application for Certification of a Carrier's Professional Health Care Review Program PDF icon

• WC-739 (2/12) Carrier's Explanation of Benefits PDF icon

Insurance Coverage Forms

• WC-337 (6/09) Notice of Exclusion

• WC-338 (7/09) Notice to Terminate Exclusion

• WC-400 (2/13) - Insurer's Notice of Issuance of Policy (fill-in form) PDF icon

• WC-400A (7/09) - Insurer's Notice of Issuance of Specific Risk Policy

• WC-401 (2/13) - Notice of Termination of Liability (fill-in form) PDF icon

• WC-401A (7/09) - Notice of Termination of Specific Risk Policy

• WC-403 (9/13) - Insurer's Notice of Name or Address Change (fill-in form) PDF icon

Las formas en el Español

• BWC-113 (Español) - Demanda de Redención PDF icon

• BWC-119 (Español) - Declaracion que Apoya el Acuerdo de Redencion PDF icon

• WC-500 (Español) - Proveedor de Rehabilitación Vocacional Declaración de Divulgación Profesional PDF icon

• BWC-544 (Español) - Declaración del Acuerdo del Trabajador PDF icon

• BWC-556 (Español) - Acuerdo Para Redimir Responsabilidad PDF icon

Litigation Forms

• WC-40 (1/12) - Request for Compliance Hearing (fill-in form) PDF icon

• WC-104A (2/13) - Application for Mediation or Hearing (fill-in form)

• WC-104B (9/13) - Health Care Services Application for Mediation or Hearing (fill-in form) PDF icon

• WC-104C (2/12) - Defendant's Application for Mediation or Hearing (fill-in form) PDF icon

• WC-105A (4/12) Work History, Work Qualifications & Training Disclosure Questionnaire (fill-in form) PDF icon

• WC-105B (4/12) Employer Disclosure Questionnaire (fill-in form) PDF icon

• WC-113 (4/12) - Redemption Order (fill-in form) PDF icon

• WC-113A (4/12) - Multiple Carrier Redemption Form (fill-in form) PDF icon

• WC-115 (3/14) - Voluntary Payment Form (fill-in form) PDF icon

• WC-119 (4/12) - Affidavit in Support of Redemption (settlement) Agreement (fill-in form) PDF icon

• WC-200 (4/12) - Opinion/Order (fill-in form)

• WC-251 (4/12) - Carrier's Response (fill-in form) PDF icon

• WC-262 (4/12) - Claim/Cross-Claim for Review (fill-in form) PDF icon

• WC-508 (1/12) - Subpoena for Production of Records (and/or) Witness Subpoena (fill-in form) PDF icon

• WC-544 (5/12) - Worker's Settlement Statement (fill-in form) PDF icon

• WC-556 (5/12) - Agreement to Redeem Liability (fill-in form) PDF icon

Misc Forms

• WC-450 Application For Authorization By Self-Insured Employer or Group Fund For Servicing Agent DEG User Account (fill-in form) PDF icon

• WC-460 Application For DEG User Account (fill-in form) PDF icon

Self-Insurance Forms

• WC-402 (8/11) Self-Insurer Application Packet (fill-in form) PDF icon

• WC-402A (8/11) Self-Insurer Request to Add or Delete Subsidiary/Affiliate (fill-in form) PDF icon

• WC-402G (9/11) Group Self-Insurer Application Packet PDF icon

• WC-402GR (9/11) Group Self-Insurer Application (fill-in form) PDF icon

• WC-404 (9/11) Service Company Application (fill-in form) PDF icon

• WC-650 (9/11) Self-Insured Group Notice of Acceptance of Membership (fill-in form) PDF icon

• WC-651 (9/11) - Notice of Termination of Membership (fill-in form) PDF icon

• Letter of Credit/Memorandum of Understanding (8/11) (fill-in form) PDF icon

• Michigan Continuous Surety Bond (8/11) (fill-in form) PDF icon

• Michigan Certificate of Specific/Aggregate Excess Liability Insurance (8/11) (fill-in form) PDF icon

• Self-Insurer's Claims Transfer Agreement (fill-in form) PDF icon

Vocational Rehabilitation Forms

• WC-110 (11/11) - Report on Rehabilitation (fill-in form) PDF icon

• WC-500 (12/11) VR Provider Professional Disclosure Statement PDF icon

• WC-502 (5/12) - Application for Agency Approval as a Rehabilitation Facility (fill-in form) PDF icon

WCA Quicklinks
 •  2014 Calculation Program
 •  Freedom of Information Act Requests
 •  Insurance Coverage Lookup
 •  Hearing Site Clickable Map
 •  State Average Weekly Wage Chart
 •  Travel Reimbursement Rates
 •  Magistrate Opinions Search
 •  Appellate Commission
QR code Home
PoliciesMichigan Survey

Copyright © 2014 State of Michigan