Wc-114 - Application For Reimbursement From The Compensation Supplement Fund
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APPLICATION FOR REIMBURSEMENT FROM THE
COMPENSATION SUPPLEMENT FUND
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
PO Box 30016, Lansing, MI 48909
Initial (For Quarter)
Corrected
Employer Name
Carrier File No.
(Type or print)
Employee Name (Last, First, MI)
Employee Street Address
City
State
Zip Code
Social Security Number
Date of Injury (MM-DD-YYYY)
Average Weekly Wage on Date of Injury
Date of Birth (MM-DD-YYYY)
Name of Insurance Company or Self-Insured
Carrier I.D. Number
Carrier Address (Street)
City
State
Zip Code
Federal Employer I.D. Number
Weekly Comp. Rate on Jan. 1, 1982
Reimbursement
Requested For:
Quarter ___________ Calendar Year _____________
Weekly Second Injury
Weekly
Total
Compensation Paid
Supplement
Weeks
Days
Fund Differential
Compensation
Supplement
Date from
Date to
Percentage
Benefits Paid
Supplement
Paid
(MM-DD-YYYY)
(MM-DD-YYYY)
Total
Reimbursement
$ ___________
Requested
Date of death
Date of redemption
Return to work
Other
Comments:
Signature of Authorized Representative (In Ink)
Name of Person to Whom Correspondence Should Be Sent (Please Print)
Date of This Report
Address
Telephone Number
NOTICE: The initial form WC-114 must be filed within three (3) months after the end of the calendar quarter in
which benefits are first paid. No subsequent reimbursements will be allowed for a period which is
more than one (1) year prior to the filing date of the form WC-114.
LARA is an equal opportunity employer/program. Auxiliary aids, services
Authority:
Workers’ Disability Compensation Act, 418.352; R408.32(2)(3)
and other reasonable accommodations are available upon request to
Completion:
Mandatory
Penalty:
Workers’ Disability Compensation Act, 418.631; 418.801
individuals with disabilities.
WC-114 (Rev. 11/11)
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