Form Ocr 107 - Michigan Workers' Compensation Notice Of Dispute Form
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2OCR 107
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Instructions
NOTICE OF DISPUTE
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
P O Box 30016, Lansing, MI 48909
1. Social Security No.
2. Date of Injury
3. Employee Name (Last, First, MI)
4. Employee Address (Street No. and Name)
5. City
6. State
7. ZIP Code
8. Employer Name
9. Federal ID No.
10. Employer Street Address
11. City
12. State
13. ZIP Code
14. Carrier or Self-Insured Name
15. NAIC or Self-Insured No.
16. ZIP Code
17. Service Company/TPA Name (if applicable)
18. Service Co./TPA ID No.
19. ZIP Code
20. Claim or File No.
21. County of Injury
22. County Code (if known)
23. Reason for Dispute
A.
Injury not work related
B.
Medical treatment not related to injury
C.
Further investigation required (please specify below)
D.
Additional information required from employee (please specify below)
E.
Vocational rehabilitation dispute only (please specify below)
F.
Other (please specify below)
Making a false or fraudulent statement for the purpose of
Authority:
Workers’ Disability Compensation Act, R408.33 (1)
obtaining or denying benefits can result in criminal or civil
Completion:
Mandatory
Penalty:
Workers’ Disability Compensation Act, 418.631; 418.801; R408.33
prosecution, or both, and denial of benefits.
This is to certify that a copy of this form has been mailed or given to the injured employee.
24. Preparer’s Name (Please print)
25. Signature
26. Telephone No.
27. Date
NOTICE TO EMPLOYEE
By filing this form, your employer or its workers’ compensation insurance company has indicated to the Workers’ Compensation Agency
that it has a question or a dispute concerning the possible workers’ compensation benefits to which you may be entitled. You may or may
not agree with the position taken by the employer or insurance company.
If you feel that you are not receiving the benefits to which you are entitled, you should discuss this with your employer or a representative
of its insurance company. If you have already done that or you are not satisfied with the discussion, you may file a formal application for
mediation or hearing. You can obtain the appropriate forms or more information by contacting the Workers’ Compensation Agency at our
toll-free number of 1-888-396-5041. Additional information may also be found on our website at
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals
with disabilities.
WC-107 (Rev. 2/13)
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