This is a double-sided form and is not available online.  To order a supply of these forms:

1. Call (517) 322-1441 or 1-888-396-5041 and press 3, then 5.
2. Send a fax to (517) 322-1808 and include your name, street address, city, state, zip code and a phone number of a contact person, along with the requested form number, name of the form, and amount needed.
3. Send an e-mail to us at wcinfo@michigan.gov and include your name, street address, city, state, zip code and a phone number of a contact person, along with the requested form number, name of the form, and amount needed.