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Get MI WC-104A 2013

Ication Type Initial Penalty Only Amended Voc Rehab Only THIS FORM TO BE USED BY EMPLOYEES ONLY. A SEPARATE WC-104A MUST BE FILED FOR EACH EMPLOYER. INCOMPLETE APPLICATIONS SHALL BE RETURNED. 1. NAME OF EMPLOYEE (Last, First, MI) 2. SOCIAL SECURITY NUMBER 4. STREET NUMBER AND NAME 8. TAX FILING STATUS 5. CITY 6. STATE 7. ZIP CODE 9. SEX 3. DATE OF BIRTH A. Single C. Married, Filing Joint B. Single, Head of Household D. Married, Filing Separate 10. DATE OF DEATH (If Applicable) M.

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