MI WC-104A 2013 free printable template
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APPLICATION FOR MEDIATION OR HEARING FORM A Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 Application Type Initial Amended Penalty
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How to fill out MI WC-104A
How to fill out MI WC-104A
01
Begin by obtaining the MI WC-104A form from the Michigan Department of Labor and Economic Opportunity website or your employer.
02
Fill in your personal information at the top of the form, including your name, address, and Social Security number.
03
Indicate the date of your injury, the type of injury, and how it occurred in the designated sections.
04
Provide information about your employer, including their name, address, and phone number.
05
Complete the section regarding medical treatment, detailing any healthcare providers involved and the nature of the treatment received.
06
Ensure you list any lost wages and the dates they were lost due to the injury.
07
Review the form for accuracy, making sure all required fields are completed.
08
Sign and date the form at the bottom before submission.
Who needs MI WC-104A?
01
Individuals who have been injured while working in Michigan.
02
Employees seeking workers' compensation benefits due to work-related injuries or illnesses.
03
Workers who need to report the details of their injury and any associated medical treatment.
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What is MI WC-104A?
MI WC-104A is a form used in the state of Michigan for reporting workers' compensation claims and other related information.
Who is required to file MI WC-104A?
Employers who have provided workers' compensation benefits to employees as part of a claim are required to file MI WC-104A.
How to fill out MI WC-104A?
To fill out MI WC-104A, you need to provide accurate information regarding the injured employee, the nature of the injury, the benefits provided, and other relevant claim details.
What is the purpose of MI WC-104A?
The purpose of MI WC-104A is to ensure proper documentation and reporting of workers' compensation claims in Michigan, facilitating the tracking and management of these claims.
What information must be reported on MI WC-104A?
MI WC-104A must include information such as the employee's name, date of injury, type of injury, benefits paid, and other pertinent details regarding the workers' compensation claim.
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