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EMPLOYEE’S REPORT OF CLAIM
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
P.O. Box 30016, Lansing, MI 48909
NOTE: A copy of this form will be sent to your employer and their workers’ compensation insurance carrier. Do not submit
any medical reports with this form.
1. Social Security Number 2. Date of Injury 3. Date of Birth (MM/DD/YYYY) 4. Employee Telephone Number
5. Employee Name (Last, First, MI) 10. Employer Name
6. Employee Street Address
11. Employer Street Address
7. Employee City
8. State
9. ZIP Code
12. Employer City
13. State
14. ZIP Code
15. Describe the type of injury and explain how it happened.
16. Are you making a claim for payment of medical expenses?
Yes No
17.
Last Day Worked
18. Have you gone back to work? Yes No
If yes, date of return ______________________________
19. Was the injury reported to your employer? Yes No
If yes, date reported ______________________________
Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in
criminal or civil prosecution, or both, and denial of benefits.
20. Employee Signature
21. Date of this report
OFFICE USE ONLY
Carrier Name
LARA is an equal opportunity employer/program. Auxiliary aids, services and other
reasonable accommodations are available upon request to individuals with disabilities.
Authority:
Completion:
Penalty:
Workers’ Disability Compensation Act, 408.31(4)
Voluntary
None
WC-117 (Rev. 4/13)
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