Multiple Carrier Redemption Form

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MULTIPLE CARRIER REDEMPTION FORM
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency/Board of Magistrates
PO Box 30016, Lansing, MI 48909
Plaintiff
Social Security Number
CARRIER 1
CARRIER 2
Employer
Employer
Insurance Company
Insurance Company
Date(s) of Injury
Date(s) of Injury
CARRIER 3
CARRIER 4
Employer
Employer
Insurance Company
Insurance Company
Date(s) of Injury
Date(s) of Injury
CARRIER
CARRIER
CARRIER
CARRIER
TOTAL
1
2
3
4
1. Attorney Fees
2. Attorney Expenses
3. Direct Payments (Medical)
4. Direct Payments (Non-medical)
5. Plaintiff’s Redemption Fee
6. Balance to Plaintiff
7. Allocated to Medical
(Not included in 3 above)
8. Total Payment
9. Cost of Annuity (If applicable)
Carrier # _______ to remit defendant’s statutory redemption fee of $100.00 directly to State of Michigan.
Carrier # _______ to complete the payment of weekly compensation of $ _____________ per week through ____________________.
Authority:
Workers’ Disability Compensation Act, 418.835; 418.836; 418.837
LARA is an equal opportunity employer/program. Auxiliary aids, services and
other reasonable accommodations are available upon request to individuals w ith
Completion:
Voluntary
disabilities.
Penalty:
None
WC-113A (4/12)

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