Supplemental Report Of Fatal Injury
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SUPPLEMENTAL REPORT OF FATAL INJURY
Michigan Department of Licensing and Regulatory Affairs
Workers' Compensation Agency
PO Box 30016, Lansing, MI 48909
THIS REPORT IS TO BE FILED BY THE EMPLOYER IMMEDIATELY AFTER THE DEATH OF AN INJURED EMPLOYEE.
I. DECEASED EMPLOYEE
1. Social Security Number
2. Date of Injury
3. Date of Death
4. Name (Last, First, Middle Initial)
5. Street Address
6. City
7. State
8. ZIP Code
II. EMPLOYER DATA
9. Employer Name
10. Federal I.D. Number
11. Street Address
12. City
13. State
14. ZIP Code
15. Amount of Burial Expenses Paid (If Not Previously Reported)
$
III. DEPENDENTS OF EMPLOYEE
18.
19.
16.
17.
Relationship to Deceased
Extent of Dependency
Name
Date of Birth
(Spouse, Child, or Other - Please Specify Other)
(Total/Partial)
20. Employer’s Signature
21. Title
22. Date
LARA is an equal opportunity employer/program. Auxiliary aids, services and
Authority:
Workers’ Disability Compensation Act, R408.31(3)
other reasonable accommodations are available upon request to individuals
Completion:
Mandatory
with disabilities.
Penalty:
Workers’ Disability Compensation Act 418.631
WC-106 (10/11)
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