Fillable Form Wc-115 - Voluntary Payment printable pdf download

Form Wc-115 - Voluntary Payment

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(Personal Service)

(Mailed)

VOLUNTARY PAYMENT FORM

_____ Day of __________ 20

Michigan Department of Licensing and Regulatory Affairs

Workers' Compensation Agency/Board of Magistrates

P.O. Box 30016, Lansing, MI 48909

Magistrate (Please print)

Plaintiff

Defendant

Plaintiff’s Social Security Number

Date of Injury

The plaintiff and defendant agree that the plaintiff's Application for Mediation or Hearing is withdrawn. The defendant

agrees to pay benefits on a voluntary basis in accordance with the following:

$____________________

Weekly benefit rate

$____________________

Less benefits to be coordinated

$____________________

Subtotal

$____________________

Plus supplemental benefit

$____________________

TOTAL

____________________ through _________________

Benefits to be paid for the period from

Medical expenses to be paid?

Yes

If yes, to whom?

Reimbursement to group carrier?

Yes

Atty. fee to be charged

Percent ______%

Amount $_____________________

Atty. Fed. I.D.# _____________________________

Amount of interest to be paid $____________________

Additional agreements (attach additional sheets if necessary)

Neither the payment of compensation nor the accepting of same by the employee or his/her dependents shall be considered

as a determination of the rights of the parties under this Act.

All benefits become due and payable on the day of personal service or the mailing date.

Plaintiff

Defendant

Representative of Plaintiff

Representative of Defendant

Date

Magistrate

LARA is an equal opportunity employer/program. Auxiliary aids, services and other

Authority:

Workers’ Disability Compensation Act 408.33(2)(b); 408.40b(3)

reasonable accommodations are available upon request to individuals with

Completion:

Voluntary

disabilities.

Penalty:

None

WC-115 (Rev. 3/14)

Form Wc-115 - Voluntary Payment

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