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Free Michigan Wc 100 Template in PDF

The Michigan WC-100 form is a crucial document used by employers to report workplace injuries and illnesses to the Michigan Department of Labor and Economic Opportunity. This form must be completed and submitted promptly when an injury results in significant consequences, such as disability, death, or specific losses. Understanding how to fill out the WC-100 accurately is essential for compliance and ensuring that employees receive the benefits they deserve.

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The Michigan WC-100 form serves as a critical document for employers in reporting workplace injuries and illnesses. This form is required to be submitted to the Workers’ Disability Compensation Agency when an employee experiences an injury or disease that arises out of their employment. It is particularly important when the injury results in a disability that lasts beyond seven consecutive days, leads to the death of an employee, or involves specific losses. The WC-100 form collects essential information about the employee, including their personal details, the circumstances surrounding the injury, and any medical treatment received. Employers must provide data regarding their business and the nature of the injury, ensuring compliance with both state and federal regulations. Timely and accurate completion of this form not only fulfills legal obligations but also aids in the management of workers' compensation claims. By adhering to the guidelines outlined in the form, employers can help ensure that affected employees receive the benefits and support they need during their recovery process.

Form Example

OCR 100

EMPLOYER'S BASIC REPORT OF INJURY

Michigan Department of Labor and Economic Opportunity

Workers’ Disability Compensation 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)

12. Tax filing status:

A. Single

9. Sex

10. Number of dependents

11. Telephone number

Male

Female

B. Single, Head of Household

C. Married, Filing Joint

D. Married, Filing Separate

II. EMPLOYER/CARRIER DATA

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

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

If time cannot be determined,

a.m.

p.m.

a.m.

p.m.

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		Yes	No
		Yes	No		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 individual listed above in space 54

WC-100 (Rev. 8/19) Front

If you are using this form as a replacement for the Form 301 to document the specifics of an injury or illness 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 f orms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses (Form 300) and the accompanying Summary (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’ Disability Compensation Agency unless it meets the conditions listed below in Section

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 loss. The original form must be mailed to the Workers’ Disability 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

LEO is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

WC-100 (Rev. 8/19) Back

▼ Michigan Wc 100 PDF Form

Document Specs

Fact Name	Description
Form Purpose	The Michigan WC-100 form is used by employers to report workplace injuries and diseases that arise during employment.
Reporting Requirements	Employers must report injuries immediately if they result in disability beyond seven consecutive days, death, or specific losses.
Employee Information	The form requires detailed employee data, including Social Security Number, date of birth, and contact information.
Employer Information	Employers must provide their name, Federal ID Number, and details about the business and insurance coverage.
Injury Details	Specific questions regarding the nature of the injury, treatment, and circumstances surrounding the incident must be answered.
Filing Timeline	The form must be completed within seven calendar days of learning about a recordable work-related injury or illness.
Governing Law	This form is governed by the Workers' Disability Compensation Act, specifically sections 408.31(1)(3) and 418.631.

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