Claim Cross Claim For Review

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CLAIM/CROSS-CLAIM FOR REVIEW
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
PO Box 30016
Lansing, Michigan 48909
Please check one:
Claim for Review
Cross-Claim for Review
INSTRUCTIONS: SEE REVERSE SIDE
1. Social Security Number
2. Employee Name (Last, First, Middle Initial)
3. Employee Street Address
4. City
5. State
6. ZIP Code
7. Party Filing this Appeal
Plaintiff
Carrier or Self-Insured
Employer (If Uninsured)
Other (Specify)
8. Employer Name
9. Federal ID Number
10. Carrier or Self-Insured Name
11. NAIC or Self-Insured Number
12. Order Number
A COPY OF THE ORDER BEING APPEALED MUST BE ATTACHED
13. Type of Order Being Appealed (Check Only One)
A.
Decision on Merits
D.
Interlocutory Decision
G.
Vocational Rehabilitation Order
B.
Dismissal of Petition
E.
Redemption Order
H.
Attorney Fees
C.
Director’s Order
F.
Advance Payment Order
I.
Other
14. Basis of Claim. This application for review of claim is based on the following grounds:
15. Transcript Required?
If no, reason:
Yes
No
16. Number of Transcript(s)
Date Transcript(s) Ordered
Hearing Dates:
17. Proof of Service Attached?
If no, reason:
Yes
No
I8. If representing yourself, please complete this section.
Signature
Telephone Number
Date Signed
19. Legal counsel, if obtained, must complete this section.
Signature
Attorney ID Number
Date Signed
P -
LARA is an equal opportunity employer/program. Auxiliary aids, services and
Authority:
Workers’ Disability Compensation Act 418.101 et seq.
other reasonable accommodations are available upon request to individuals
Completion:
Voluntary
with disabilities.
Penalty:
Order Stands
WC-262 (Rev. 4/12) Front

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