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  • Application For Mediation Or Hearing Form B

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E IDENTIFICATION 1. Employee Name (Last, First, MI) 2. Social Security Number 5. Street Address 6. City 3. Date of Birth 8. ZIP Code 7. State 4. Date of Injury 9. County of Injury EMPLOYER IDENTIFICATION 10. Employer Name 11. Federal I.D. Number 12. Street Address 13. City 14. State 16. Contact Person 15. ZIP Code 17. Telephone Number CARRIER IDENTIFICATION 18. Carrier or Self-Insured Name 19. NAIC or Self-Insured Number 20. Street Address 21. City 22. State 24. Claim Handl.

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The Michigan Workers' Disability Compensation Act (Act) established protections for workers who get sick or injured from the work they do. It makes benefits available to most workers regardless of who is at fault for the injury or illness.

If you're unable to work at all and are entitled to wage-loss benefits, you'll generally receive 80% of your pre-injury wages (based on the after-tax value of the average weekly wages in the 39 highest-paid weeks out of the 52 weeks before you were injured or became ill).

Mileage and travel expenses can be reimbursed under workers' comp. This is a hidden benefit that insurance companies do not always tell people about. The Workers' Disability Compensation Agency has now updated its travel reimbursement rates for injured employees. The Michigan mileage reimbursement rate 2024 is $0.67.

When an injury/illness occurs: Immediately notify your supervisor. Seek treatment at an Occupational Health Care Clinic. Submit a Workers' Compensation Claim: Apply Online, or. Print, complete, and fax a State of Michigan Workers' Compensation Claim Form.

When an injury/illness occurs: Immediately notify your supervisor. Seek treatment at an Occupational Health Care Clinic. Submit a Workers' Compensation Claim: Apply Online, or. Print, complete, and fax a State of Michigan Workers' Compensation Claim Form.

In case of the death of the employee, the claim shall be made within 2 years after death. The employee shall provide a notice of injury to the employer within 90 days after the happening of the injury, or within 90 days after the employee knew, or should have known, of the injury.

After you report your injury, there is a seven-day waiting period before you can get wage loss benefits. The seven days include weekends and holidays. You are eligible for benefits on the eighth day.

■How Long Do I Have To File A Claim The statute states that you should provide notice of injury to the employer within 90 days of the injury. However, you have up to two years from the date of injury, or the date the disability manifests itself, to file a workers' compensation claim.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232