MI WC-104A 2019 free printable template
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OCR 104AInstructionsAPPLICATION FOR MEDIATION OR HEARING FORM A Michigan Department of Labor and Economic Opportunity Workers Disability Compensation Agency P.O. Box 30016, Lansing, MI 48909Application
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How to fill out MI WC-104A
How to fill out MI WC-104A
01
Begin by downloading the MI WC-104A form from the Michigan Department of Licensing and Regulatory Affairs website.
02
Fill in the claimant's information, including name, address, and contact details.
03
Provide the date of injury or illness in the designated section.
04
Include the name and address of the employer where the injury occurred.
05
Detail the nature of the injury or illness, explaining how and where it happened.
06
If applicable, indicate any medical treatment received by the claimant following the injury.
07
Review all information for accuracy and completeness before submitting.
08
Sign and date the form at the bottom where indicated.
Who needs MI WC-104A?
01
Any employee in Michigan who has suffered a work-related injury or illness and needs to file a claim for workers' compensation benefits.
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What is MI WC-104A?
MI WC-104A is a form used in Michigan for reporting wage loss benefits related to workers' compensation claims.
Who is required to file MI WC-104A?
Employers and insurance carriers are required to file MI WC-104A when there are wage loss benefits being provided to an employee.
How to fill out MI WC-104A?
To fill out MI WC-104A, ensure you provide accurate information regarding the employee's wage loss period, wages before and after the incident, and any relevant benefits received.
What is the purpose of MI WC-104A?
The purpose of MI WC-104A is to document and report wage loss benefits to ensure compliance with workers' compensation laws in Michigan.
What information must be reported on MI WC-104A?
The information that must be reported on MI WC-104A includes the employee's name, claim number, period of wage loss, pre-injury average weekly wage, and any wages earned during the claim period.
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