Get Form Wc-107 - State Of Michigan - Mi
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How to use or fill out the Form WC-107 - State Of Michigan - Mi online
Filling out the Form WC-107 is an essential process for reporting disputes related to workers' compensation in Michigan. This guide provides clear, step-by-step instructions to help you accurately complete the form online, ensuring you have all necessary information at hand.
Follow the steps to complete the Form WC-107 successfully.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the employee's Social Security number in field 1. Ensure the number is accurate as it is crucial for identifying the employee.
- In field 2, specify the date of the injury. Use the format MM/DD/YYYY to avoid confusion.
- Provide the employee's full name in field 3, ensuring the last name, first name, and middle initial are correctly included.
- Enter the employee's address in field 4. Be sure to include the street number and name.
- Fill in the city in field 5, followed by the state in field 6, and the ZIP code in field 7.
- For the employer's details, enter their name in field 8 and complete fields 9 to 13 with the employer's federal ID number, street address, city, state, and ZIP code.
- If applicable, provide the name and ID number of the service company or third-party administrator in fields 14 and 15.
- Fill in the claim or file number in field 20, followed by the county of injury in field 21 and the county code in field 22, if known.
- In field 23, indicate the reason for the dispute by checking the appropriate box. If further details are needed, please specify in the space provided.
- Complete the preparer's name in field 24, sign the form in field 25, and provide a contact telephone number in field 26. Finally, enter the date in field 27.
- Review the completed form carefully for accuracy. Once finished, save your changes, and choose to download, print, or share the form as needed.
Complete your Form WC-107 online today to ensure timely submission.
File an exclusion form with the Insurance Compliance Division of the Agency. This division can be reached at 517-284-8922. It is a form provided by the Insurance Compliance Division (WC-337) which is completed by the employer and filed with the Agency.
Fill Form WC-107 - State Of Michigan - Mi
A submitted form must be identical to the WC-107 provided on the Workers' Disability Compensation Agency website. By filing this form, your employer or its workers' compensation insurance company has indicated to the Workers' Disability. Form WC-107: Must be filed with the WDCA if a claim is disputed. If an employer denies a claim for benefits, they must provide the claimant with a Form WC107 "Notice of Dispute. Form WC107: Must be filed with the WDCA if a claim is disputed. You are entitled to weekly workers' compensation benefits if you suffer a wage loss for more than seven consecutive. A copy of the form WC-107, notice of dispute, shall must be mailed or given provided to the injured employee. Employees who find their workman's comp benefits disputed should receive a Form WC-107. This should explain the reason for non-payment. ⇨ Form WC-107: must be filed with the WCA if a claim is disputed.
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