Employee'S Report Of Claim

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EMPLOYEE’S REPORT OF CLAIM
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
P.O. Box 30016, Lansing, MI 48909
NOTE: A copy of this form will be sent to your employer and their workers’ compensation insurance carrier. Do not submit
any medical reports with this form.
1. Social Security Number
2. Date of Injury
3. Date of Birth (MM/DD/YYYY)
4. Employee Telephone Number
5. Employee Name (Last, First, MI)
10. Employer Name
6. Employee Street Address
11. Employer Street Address
7. Employee City
8. State
9. ZIP Code
12. Employer City
13. State
14. ZIP Code
15. Describe the type of injury and explain how it happened.
Are you making a claim for payment of medical expenses?
Last Day Worked
16.
17.
Yes
No
Have you gone back to work?
Yes
No
Was the injury reported to your employer?
Yes
No
18.
19.
If yes, date of return
If yes, date reported
______________________________
______________________________
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.
20. Employee Signature
21. Date of this report
OFFICE USE ONLY
Carrier Name
Authority:
Workers’ Disability Compensation Act, 408.31(4)
LARA is an equal opportunity employer/program. Auxiliary aids, services and other
Completion:
Voluntary
reasonable accommodations are available upon request to individuals with disabilities.
Penalty:
None
WC-117 (Rev. 4/13)

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