Form Wc-100 - Employer'S Basic Report Of Injury - 2013

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OCR 100

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EMPLOYER'S BASIC REPORT OF INJURY

Michigan Department of Licensing and Regulatory Affairs

Workers’ Compensation Agency

PO Box 30016, Lansing, MI 48909

An employer shall report immedia tely to the agen cy on Form WC-100 all injuries, including diseases, which arise out of and in the course of the employment, or on which a claim is

made and result in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific losses. In case of death, an

employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures.

EMPLOYEE DATA

1. Social Security Number

2. Date of injury

3. Employee name (Last, First, MI)

4. Address (Number & Street)

5. City

6. State

7. ZIP Code

8. Date of birth (MM/DD/YYYY)

9. Sex

10. Number of dependents

11. Telephone number

Male

Female

12. Tax filing status:

A. Single

B. Single, Head of Household

C. Married, Filing Joint

D. Married, Filing Separate

EMPLOYER

CARRIER DATA

13. Employer name

14. Federal ID Number

15. Injury location code

16. Mailing location code

17. UI number

18. Type of business (SIC/NAICS)

19. Employer street address

20. City

21. State

22. ZIP code

23. Insurance company name (if employer not self-insured)

24. Insurance company telephone number (if known)

III

INJURY

MEDICAL DATA

25. Last day worked

26. Date employee returned to work (if applicable)

27. Did employee die?

28. If yes, date of death

Yes

29. Injury city

30. Injury state

31. Injury county

32. Did injury occur on employer's premises?

Yes

No (

If no, see item 53)

33. Case number from OSHA/MIOSHA log

34. Time employee began work

35. Time of event

If time cannot be determined,

check here

a.m.

p.m

a.m.

p.m

36. What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.

37. How did the injury occur? Examples: “When ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during replacement”

38. Describe the nature of injury or illness

39. Part of body directly affected by the injury or illness

40. What object or substance directly harmed the employee? Examples: concrete floor, chlorine, radial arm saw. If this question does not apply to the incident, leave it blank.

41. Name of physician or other health care professional

42. Was employee treated in an emergency room?

43. Was employee hospitalized overnight as an in-patient?

Yes

44. If treatment was given away from the worksite, where was it given? (Include name, address, city, state and ZIP code of facility)

OCCUPATION AND WAGE DATA

45. Date hired

46. Total gross weekly wage (highest 39 of 52)

47. Number of weeks used

48. Value of discontinued fringes

49. Occupation (Be specific)

50. Was employee a volunteer worker?

51. Was employee certified as vocationally handicapped?

Yes

52. Date employer notified by employee

53. If temporary service agency, provide name/address of employer where injury occurred.

I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE

PREPARER DATA

Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits.

54. Preparer's name (Please print or type)

55. Preparer's signature

56. Telephone number

57. Date prepared

Notice to employee: Questions or errors should be reported immediately to the individual listed above in space 54

WC-100 (Rev. 2/13) Front