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Get Mi Wc-104a 2013
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How to fill out the MI WC-104A online
Filling out the MI WC-104A form is an important step for employees seeking mediation or a hearing regarding their workers’ compensation claim. This guide will provide you with clear, step-by-step instructions to help you navigate the online application process effectively.
Follow the steps to complete your MI WC-104A form accurately.
- Press the ‘Get Form’ button to access the MI WC-104A form and open it in your editor.
- Select the application type by checking one of the four boxes available: Initial, Amended, Penalty Only, or Voc Rehab Only. Ensure you choose the correct application type that applies to your situation.
- Fill in your personal information under numbers 1-13. This includes your name, social security number, date of birth, address, and tax filing status.
- Under numbers 14-19, provide the employer's information, including the name, address, and federal identification number if known.
- In numbers 20-24, document your employment dates, earnings, location of injury, and the dates of injury you are claiming. Select whether your earnings are hourly or weekly.
- Describe the nature of your disability and how the incident occurred in number 25. Specify the relief you are seeking.
- Answer questions 26-33 regarding additional employment and claims, providing further information as necessary.
- Complete number 34 by indicating any other benefits you are currently receiving or have received during your period of disability. Specify weekly or monthly amounts.
- List the healthcare providers who treated you in number 35, including their names and addresses.
- In numbers 36 and 37, provide names and addresses of any witnesses to your injury, ensuring not to include anyone currently employed by that employer.
- Sign the certification at the end of the form, affirming that the information provided is accurate to the best of your knowledge.
- If applicable, complete the attorney identification section and provide relevant details if you are represented by an attorney.
- Once all fields are complete and verified, save your changes. You may choose to download, print, or share your completed MI WC-104A form.
Complete your MI WC-104A form online today to ensure your workers' compensation claim is properly processed.
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To file a Workers' Comp claim in Michigan, start by notifying your employer about the injury or illness. You will then need to complete the necessary forms, including the MI WC-104A, which provides critical information about your situation. Make sure to keep copies of all documents and follow up to ensure your claim is processed efficiently.
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