Fillable Printable Employer's Basic Report of Injury - Michigan

Employer's Basic Report of Injury - Michigan

EMPLOYER'S BASIC REPORT OF INJURY

Michigan Department of Licensing and Regulatory Affairs

Workers’ Comp

ensation Agency

PO Box 30016, Lansing, MI 48909

An employer shall report immediately to the agency on Form WC-100 all injuries, including diseases, which arise out of and in the course of the employment, or on which a claim is

made and result in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific losses. In case of death, an

employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures.

I. EMPLOYEE DATA

1. Social Security Number 2. Date of injury 3. Employee name (Last, First, MI)

4. Address (Number & Street) 5. City 6. State 7. ZIP Code

8. Date of birth (MM/DD/YYYY) 9. Sex 10. Number of dependents 11. Telephone number

Male

Female

12. Tax filing status: A. Single B. Single, Head of Household C. Married, Filing Joint D. Married, Filing Separate

II. EMPLOYER/CARRIER DAT A

13. Employer name 14. Federal ID Number

15. Injury location code 16. Mailing location code 17. UI number 18. Type of business (SIC/NAICS)

19. Employer street address 20. City 21. State 22. ZIP code

23. Insurance company name (if employer not self-insured) 24. Insurance company telephone number (if known)

III. INJURY/MEDICAL DATA

25. Last day worked 26. Date employee returned to work (if applicable) 27. Did employee die? 28. If yes, date of death

Yes No

29. Injury city 30. Injury state 31. Injury county 32. Did injury occur on employer's premises?

Yes No (If no, see item 53)

33. Case number from OSHA/MIOSHA log 34. Time employee began work 35. Time of event

a.m. p.m. a.m. p.m.

If time cannot be determined,

check here

36. What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.

37. How did the injury occur? Examples: “When ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during replacement”

38. Describe the nature of injury or illness 39. Part of body directly affected by the injury or illness

40. What object or substance directly harmed the employee? Examples: concrete floor, chlorine, radial arm saw. If this question does not apply to the incident, leave it blank.

41. Name of physician or other health care professional 42. Was employee treated in an emergency room? 43. Was employee hospitalized overnight as an in-patient?

Yes No Yes No

44. If treatment was given away from the worksite, where was it given? (Include name, address, city, state and ZIP code of facility)

IV. OCCUPATION AND WAGE DATA

45. Date hired 46. Total gross weekly wage (highest 39 of 52) 47. Number of weeks used 48. Value of discontinued fringes

49. Occupation (Be specific) 50. Was employee a volunteer worker? 51. Was employee certified as vocationally handicapped?

Yes No

52. Date employer notified by employee 53. If temporary service agency, provide name/address of employer where injury occurred.

V. PREPARER DATA I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE

Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits.

54. Preparer's name (Please print or type) 55. Preparer's signature 56. Telephone number 57. Date prepared

Notice to employee: Questions or errors should be reported immediately to the indi vidual listed above in space 54

WC-100 (Rev. 2/13) Front

If you are using this form as a replacement for the Form 301 to document the specifics of an injury or ill ness for

purposes of compliance with the work-related injury and illness logging requirements, follow the instructions in

Section A only.

If you are using this form to report a workers’ compensation injury, follow the instructions in Section A and B.

Section A

This form can be used in lieu of the MIOSHA Form 301, Injury and Illness Incident Report. It is one of the first

forms you must fill out when a re cordable work-related injury or il lness has occurred. Together with the Log of

Work-Related Injuries and Illnesses (Form 300) and the accompanying Summar y (Form 300A), these forms help

the employer and MIOSHA develop a picture of the extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred,

you must fill out questions 1-9, 27-28, 33-45 and 54-57.

According to Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974,

Part 11, Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, you must keep this

form on file for 5 years following the year to which it pertains.

DO NOT mail this form to the Workers’

Compensation Agency unless it meets the conditions listed below in Section B.

Section B

You must complete all questions on this form if the injury or disease results in any of the following: (a) Disability

extending beyond seven (7) consecutive days, not including the date of injury; (b ) Death; (c) Specific lo ss. The

original form must be mailed to the Workers’ Compensation Agency, P.O. Box 30016, Lansing, MI 48909.

Authority: Workers' Disability Compensation Act, 408.31(1)(3)

Completion:

Mandatory

Penalty: Workers' Disability Compensation Act, 418.631

LARA is an equal opportunit y employer/program. Auxiliary aids,

services and other reasonable accommodations are available upon

request to individuals with disabilities.

WC-100 (Rev. 10/11) Back