State Of Michigan Workers' Compensation Claim Form
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2STATE OF MICHIGAN
Instructions on back
Workers’ Compensation Claim Form
York Risk Services Group is the State of Michigan’s Worker’s Compensation Third Party Administrator (TPA)
1. Employee Information
Last Name
First Name
M.I.
Employee I.D
Home Address
City
State
Zip Code
Male
Date of Birth
Home/Cell Telephone Number
Work Telephone Number
Date of Hire (mm/dd/yy)
Female
Job Classification
Department/Agency
Location/Work Site
Supervisor Contact Information
Supervisor's Name
Phone:
Email:
2. Injury/Illness Information
Time of Injury or Illness
Time employee began work
Date of injury or illness
Did the injury cause employee death?
No
Yes Date of death:
A.M
P.M
A.M.
P.M.
What were you doing just before the injury occurred? Describe the activity, as well as the tools, equipment, or material the employee was using.
What happened? Examples: “When ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during repair.”
What was the injury, including all affected body parts in order of severity?
What object or substance directly harmed you? (Example: grease, chair,
Please designate right or left. (Example: burn left index finger, puncture
needle, inmate, client, fumes, concrete floor, etc.)
right arm, scratch left leg, fracture right ankle, strained lower back,
contusion head, etc.)
Did you take time off work?
Injury or illness reported to (Name and Title)
Date reported to employer
Yes
No
Name of witness(es)
Was this injury the result of an
Last Day worked
automobile accident?
Yes
No
Return to Work Date
If yes, was it a state owned vehicle?
Date of next doctor appointment
Yes
No
Occurred on Employer Premises
Location of Injury/Illness (Building, Address, Location within the building)
County
Yes
No
Did you receive medical treatment?
Yes
No
Did injury require treatment in an emergency room?
Yes
No
Medical provider name, address and telephone number
Were you hospitalized overnight as an
Name and address of healthcare facility
inpatient?
Yes
No
How many days in the hospital?
Medical Provider’s Diagnosis
Was a prescription given?
Did you return to your regular job?
Work restrictions related to the injury/illness?
Yes
No
Yes
No
Yes
No
In consideration for receiving disability benefits under the State of Michigan Disability Benefit Program (Program) before providing all required proof of
other income, and understanding that such payments may later be determined to exceed benefits due under the Program, I hereby agree to reimburse the
State any benefits paid under the Program for which I am ineligible because of benefits received from any source that the Program’s terms require offset
from disability benefits.
I authorize the State to (1) deposit my first Workers’ Disability Compensation payment to re-credit the proper amount of any leave credits used to keep me
in full pay status and (2) process other necessary adjustments consistent with Civil Service rules and appropriate law. I will receive a check for any
remaining balance. After my first check, CMI, A York Risk Services Company will send any subsequent Workers’ Disability Compensation payments
directly to me.
Employee Signature
Date
3. HR/DMO/DMU use only
Reported to TPA by (Name and Classification)
Date reported to TPA
Telephone Number
Email Address
Case number from the MIOSHA log
Office of the State Employer 12/27/2016
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