State Of Michigan Workers' Compensation Claim Form Page 2
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2State of Michigan Worker’s Compensation Claim Form
Instructions
Department
Employee
Agriculture and Rural Development
Civil Rights
Civil Service Commission
Education
1. Immediately notify your supervisor of the work related injury/illness.
Environmental Quality
2. Complete sections 1 and 2 of the claim form including your signature and
Gaming Control Board
the date of signature.
Insurance and Financial Services
3. Fax the completed form to the Civil Service Commission Disability
Licensing and Regulatory Affairs
Management Office (DMO) at 517-241-9926.
Lottery
Michigan Land Bank Authority
4. Provide a copy of the claim form to your supervisor and retain a copy for
Military and Veterans Affairs
your records.
Natural Resources
DTMB
**For questions, contact the DMO at 877-766-6447, select option 2.**
Transportation
Treasury
Unemployment Insurance Agency
Workforce Development Agency
Attorney General
Auditor General
1. Immediately notify your supervisor of the work related injury/illness.
Community Health
2. Complete sections 1 and 2 of the claim form including your signature and
Legislative Service Bureau
the date of signature.
MEDC
3. Provide a copy of the completed claim form to your supervisor and HR
MSHDA
office.
Michigan State Capitol Commission
4. Retain a copy for your records.
Michigan Strategic Fund
Secretary of State
**For questions, contact your HR office.**
State Police
1. Immediately notify your supervisor of the work related injury/illness.
2. Complete sections 1 and 2 of the claim form including your signature and
the date of signature.
Department of Corrections
3. Provide a copy of the claim form to your supervisor and HR office.
4. Retain a copy for your records.
**For questions, please contact the DMU at 877-443-6362.**
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Parent category: Legal