Fillable Redemption Order printable pdf download

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Personal Service

Mailed

REDEMPTION ORDER

Michigan Department of Licensing and Regulatory Affairs

Day of

Workers’ Compensation Agency/Board of Magistrates

PO Box 30016, Lansing, MI 48909

Magistrate (please print)

Plaintiff Name

Full Social Security Number

Address

Defendant(s)

Carrier(s)

If more than one defendant/carrier, also complete and attach Multiple Carrier Redemption Form WC-113A

The agreement to redeem the defendant’s entire

workers’ compensation liability for injuries sustained by the plaintiff on

has

been considered by a Magistrate. IT IS ORDERED that this agreement to redeem the defendant’s entire

liability for workers’

disability compensation benefits by the payment of $

APPROVED

DENIED.

Medical left open _____ (only if initialed by Magistrate)

IT IS FURTHER ORDERED that the above sum be paid as follows:

AMOUNT

PAYABLE TO / FOR

ATTORNEY

Fees $

Federal ID #

Expenses $

MEDICAL PAYMENTS (include Federal ID#)

OTHER PAYMENTS

100.00

State of Michigan for statutory redemption fee

PLAINTIFF

Cost of annuity, if applicable

Balance directly to plaintiff

Do not write in this area.

IT IS FURTHER ORDERED that defendant remit defendant’s statutory

redemption fee of $100.00 directly to the State of Michigan.

IT IS FURTHER ORDERED that defendant shall also continue the payment of

weekly compensation of $

per week through

Social Security Administration Information

The worker is currently age

and has a remaining life expectancy of

years.

The net payment of $

is allocated at the rate of $

per month.

Signed this _______ day of ____ _ _________, 20 _______ County of _________________. Magistrate

If a request by any of the parties for review by the director, or notice of review on the director’s own motion, is not filed with the Agency within 15 days from

personal service, or if mailed, th e mailing date o f this orde r, it shall stand as th e final decis ion of the Wo rkers’ Compensation Agency.

Payment of

benefits pursuant to this order and redemption fees are due upon expiration of the appeal period. Denial of this agreement does not discharge the

liability for red emption fees. Se nd one copy of this order w ith your payment. Checks are to be made pa yable to the State of Michigan and m ailed to

WCA Redemption Fees, PO Box 30646, Lansing, Michigan 48909.

Do not write in this area.

LARA is an equal opportunity employer/program. Auxiliary aids, services and other

reasonable accommodations are available upon request to individuals with disabilities.

Authority: Workers’ Disability Compensation Act 418.835; 418.836; 418.837

Completion: Voluntary; Penalty: None

WC-113 (Rev. 4/12)