Ocr 104a, Application For Mediation Or Hearing
Download a blank fillable Ocr 104a, Application For Mediation Or Hearing in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Ocr 104a, Application For Mediation Or Hearing with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4OCR 104A
Instructions
APPLICATION FOR MEDIATION OR HEARING – FORM A
Michigan Department of Licensing and Regulatory Affairs
Application Type
Workers’ Compensation Agency
Initial
Penalty Only
P.O. Box 30016, Lansing, MI 48909
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
3. DATE OF BIRTH
4. STREET NUMBER AND NAME
8. TAX FILING STATUS
A. Single
C. Married, Filing Joint
5. CITY
6. STATE
7. ZIP CODE
B. Single, Head
D. Married, Filing
of Household
Separate
9. SEX
10. DATE OF DEATH (If Applicable)
Male
Female
11. NAME OF DEPENDENTS
12. RELATIONSHIP TO EMPLOYEE
13. BIRTH DATE
14. NAME OF EMPLOYER
20. DATES OF EMPLOYMENT
FROM:
TO:
15. FEDERAL I.D. NUMBER (If Known)
21. EARNINGS
$
HOURLY/WEEKLY
16. STREET ADDRESS
22. CITY OF INJURY
17. CITY
18. STATE
19. ZIP CODE
23. COUNTY OF INJURY
24. DATE(S) OF INJURY
DURATION OF DISABLEMENT
INSURANCE CARRIER
(DO NOT FILL IN)
FROM
TO
25.
DESCRIBE THE NATURE OF THE DISABILITY AND THE MANNER IN WHICH THE INJURY OR DISABLEMENT OCCURRED, AND SPECIFY THE RELIEF SOUGHT.
26.
DID THE EMPLOYEE HAVE ANY OTHER EMPLOYMENT AT THE TIME OF THE INJURY?
YES
NO
IF YES, LIST NAME AND ADDRESS OF THE EMPLOYER AND GROSS WEEKLY WAGE.
HAS A CLAIM BEEN FILED WITH THIS SECOND EMPLOYER?
YES
NO
27.
HAS THE EMPLOYEE HAD ANY EMPLOYMENT SINCE THE DATE OF INJURY?
YES
NO
IF YES, LIST THE NAME AND ADDRESS OF THE EMPLOYER.
28.
DOES THIS APPLICATION INVOLVE A DISPUTED CLAIM FOR MEDICAL BENEFITS?
YES
NO
IF YES, GIVE APPROXIMATE AMOUNT.
29.
DOES THIS APPLICATION INVOLVE A DISPUTED CLAIM FOR WAGE LOSS BENEFITS?
YES
NO
IF YES, HAS THE DISABILITY NOW ENDED?
YES
NO
30.
HAS THE EMPLOYEE RETURNED TO WORK? IF YES, DATE OF RETURN
/
/
YES
NO
WC-104A (Rev. 2/13) FRONT
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal