Claim Cross Claim For Review Page 2
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1
2INSTRUCTIONS FOR COMPLETING WC-262
A Claim for Review must be filed within 30 days of the mailing date of the magistrate’s order, or the order stands as final.
However, all redemption, advance payment, attorney fee, and director’s orders must be filed within 15 days, or the order
stands as final.
The completed form should be sent to the address on the front of this form along with a copy of the order being
appealed. A separate Claim for Review must be filed for each order being appealed. If you require more space than is
provided on this form, use a separate sheet of paper to provide the additional information and include the employee’s
name and social security number. Please note on the application that the required information is on an attached sheet.
1. Social Security Number
Enter the social security number of the injured employee.
2. Name of Employee
Enter the complete name of the injured employee.
3-6. Employee Address
Enter the street address, city, state and ZIP code of the injured employee.
Indicate which party is filing this appeal. If other, please specify. Only one box
7. Party filing this appeal
should be checked.
8. Employer Name
Enter the name of the employer involved in the appeal.
Enter the FEIN (Federal Employer ID Number) of the employer listed in Item 8,
9. Federal ID Number
if known.
Enter the name of the insurance carrier or self-insured employer involved in
10. Carrier or Self-Insured Name
this appeal.
Enter the NAIC or self-insured number of the carrier or self-insured listed in
11. NAIC or Self-Insured Number
Item 10, if known.
Enter the 9-digit number located at the top of the order which is being
12. Order Number
appealed. The first six digits represent the mailed date.
Indicate which type of order is being appealed. If Box A, B, C, or D is checked,
13. Type of Order Being Appealed
any future filings on this appeal must be sent to the Workers’ Compensation
Appellate Commission, PO Box 30468, Lansing, MI 48909.
14. Basis of Claim
Indicate the grounds upon which this Claim for Review is based.
15. Transcript Required/Reason
Indicate whether transcript(s) are required. If no, specify the reason.
Indicate the number of transcript(s) and the date they were ordered (if
Number of Transcript(s)/
16.
required). Also indicate the hearing date(s) in which testimony was taken.
Date Transcript(s) Ordered
Indicate whether proof of service is attached. If not attached, specify the
17. Proof of Service Attached
reason.
If representing yourself, please sign and date this form and provide telephone
18. Applicant Signature
number.
If legal counsel is obtained, the attorney must sign and date this form and
19. Attorney Signature
provide attorney ID number.
WC-262 (Rev. 4/12) Back
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