Form WC-100 "Employer's Basic Report of Injury" - Michigan

What Is Form WC-100?

This is a legal form that was released by the Michigan Department of Licensing and Regulatory Affairs - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2013;
  • The latest edition provided by the Michigan Department of Licensing and Regulatory Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form WC-100 by clicking the link below or browse more documents and templates provided by the Michigan Department of Licensing and Regulatory Affairs.

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Download Form WC-100 "Employer's Basic Report of Injury" - Michigan

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OCR 100
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EMPLOYER'S BASIC REPORT OF INJURY
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
PO Box 30016, Lansing, MI 48909
An employer shall report immedia tely to the agen cy 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 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
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
If time cannot be determined,
check here
a.m.
p.m
a.m.
p.m
.
.
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
52. Date employer notified by employee
53. If temporary service agency, provide name/address of employer where injury occurred.
I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE
.
V
PREPARER DATA
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. 2/13) Front
OCR 100
Go to Instructions
Print
Reset
EMPLOYER'S BASIC REPORT OF INJURY
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
PO Box 30016, Lansing, MI 48909
An employer shall report immedia tely to the agen cy 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 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
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
If time cannot be determined,
check here
a.m.
p.m
a.m.
p.m
.
.
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
52. Date employer notified by employee
53. If temporary service agency, provide name/address of employer where injury occurred.
I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE
.
V
PREPARER DATA
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. 2/13) Front