Get Reset Print Application For Mediation Or Hearing Form C Michigan Department Of Licensing And

Filling out the Reset Print Application for Mediation or Hearing Form C can be a straightforward process when approached step by step. This guide provides clear instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by identifying the party submitting the application — this could be the insurance company, a self-insured employer, an attorney, or other. Clearly indicate this in the designated box.
3. Provide the name of the employee in the format of last name, first name, and middle initial. Next, enter the employee's social security number and date of birth.
4. Fill in the employee's street address, city, state, and ZIP code. Accurate contact information is crucial.
5. Next, enter the name of the employer and the county where the injury occurred. If the federal ID number is known, include that as well.
6. Complete the employer’s street address, city, state, and ZIP code.
7. List the date(s) of injury. If additional employers and their corresponding injury dates need to be added, provide that information in the specified areas.
8. Under the insurance carrier sections that are not to be filled in, leave these fields blank as instructed.
9. Indicate any petitions being filed, such as a petition to stop weekly benefits, fix fees, or recoup funds. Provide detailed explanations in the areas provided.
10. Fill in the name of the party submitting the form and their street address, city, state, and ZIP code.
11. If applicable, provide the attorney's name, attorney ID number, and any relevant identification numbers.
12. Finally, enter the date, name of the preparer, and ensure the preparer signs the form. Review all entered information for accuracy.
13. Once all sections are completed, save changes, download, or print the form as necessary. Ensure to share it with the relevant parties.

Begin completing the Reset Print Application for Mediation or Hearing Form C online today.