Get Form Wc-117h - State Of Michigan - Mich

Filling out the Form WC-117H is an important step in the process of submitting a claim for workers' compensation in Michigan. This guide provides a clear and comprehensive overview of each section of the form to help users navigate the process smoothly.

Follow the steps to successfully complete the Form WC-117H.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section labeled 'Employee to complete this section,' fill in your name as Last, First, followed by your middle initial. Enter your Social Security number accurately.
3. Provide your complete address including city, state, and zip code. Include your telephone number for contact purposes.
4. State your date of birth and the employer's name. Include the name of your direct supervisor and their telephone number, along with the employer's address including city, state, and zip code.
5. Describe the type of injury you sustained and provide a brief explanation of how it occurred. Be specific, as this information is crucial for your claim.
6. Indicate the date of your injury and your last day worked. Answer whether you have returned to work after the injury.
7. Confirm if the injury was reported to your employer. If yes, provide the date of the report and your date of return if applicable.
8. Sign and date the report to certify the information provided is accurate. It’s important to note that false statements may lead to prosecution.
9. In the second section labeled 'Provider to complete this section,' your healthcare provider needs to fill in their name, telephone number, and address.
10. Ensure that the employer’s representative who authorized treatment completes their details, including telephone number and address.
11. Lastly, the healthcare provider should sign and date the form, and indicate the name of the carrier, self-insured, or group fund responsible for the claim.
12. After completing the form, review it for accuracy. You can then save your changes, download, print, or share the form as needed.

Get started on completing your Form WC-117H online today!