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WORKERS COMPENSATION AGENCY SERVICE COMPANY APPLICATION Michigan Department of Labor and Economic Opportunity Workers Disability Compensation Agency Reinsured Programs PO Box 30016 Lansing, MI 48909LEO

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How to fill out form wc-404 service company

01

Step 1: Read the form WC-404 Service Company instructions thoroughly.

02

Step 2: Fill out the 'Employer Information' section with the necessary details, including the name, address, and contact information of the company.

03

Step 3: Provide the same information for the workers' compensation insurance company in the 'Insurance Carrier Information' section.

04

Step 4: Complete the 'Claim Information' section, including the date of injury, type of injury, and the injured worker's information.

05

Step 5: Attach any supporting documentation or evidence related to the claim, such as medical records or incident reports.

06

Step 6: Review the filled-out form for accuracy and completeness.

07

Step 7: Sign and date the form in the designated fields.

08

Step 8: Submit the completed form WC-404 Service Company to the appropriate authority or department.

Who needs form wc-404 service company?

01

Form WC-404 Service Company is required by employers who need to report workers' compensation claims to the relevant authority or department.

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What is form wc-404 service company?

Form WC-404 for service company is a document used to report work-related injuries and illnesses for employees in the service industry.

Who is required to file form wc-404 service company?

Service companies are required to file Form WC-404 for any work-related injuries or illnesses that occur within their organization.

How to fill out form wc-404 service company?

Form WC-404 can be filled out by providing detailed information about the employee, the nature of the injury or illness, and any treatment received.

What is the purpose of form wc-404 service company?

The purpose of Form WC-404 is to ensure that all work-related injuries and illnesses are properly documented and reported for compliance and insurance purposes.

What information must be reported on form wc-404 service company?

Information such as employee details, date of injury, description of injury, treatment received, and any ongoing medical care must be reported on Form WC-404.

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