Michigan > Workers Comp
Instructions For Notice Of Compensation Payments Form With Examples BWC-701 - Michigan
| Instructions For Notice Of Compensation Payments Form With Examples Form. This is a Michigan form and can be used in Workers Comp . |
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GENERAL INFORMATION Form 701 The Form BWC-701 (hereafter referred to as Form 701) is used to report to the Bureau payment of weekly compensation benefits made to the employee. Attorney fees, rehabilitation costs, medical expenses, etc. should not be reported on the form. Burial expenses must be reported by the employer on Form BWC-106 or a receipt of payment will be requested. The filing number should always be #1 the first time the Form 701 is submitted for a claim, and then increase sequentially for subsequent filings. It is critical that all subsequent filings contain the exact SSN and DOI that was reported on the first filing. If this information was previously reported in error, the correction(s) should be clearly marked on the form. Friend of the Court payments should not be reported to the Bureau. All Bureau orders have a nine digit number written in the upper right hand corner consisting of the mailed date and a three digit sequential number. All Form 701's that are filed pursuant to an award (basis of payment anything other than "A") should have the order number included in the space provided below section D. Redemptions and advance payments do not need to be reported on a Form 701. If the redemption involves a claim which is in payment status, the system will automatically close out the weekly payments assuming that the weekly rate, date of injury and carrier listed on the redemption order match the information on the latest Form 701. If not, a Form 701 must be filed closing out the weekly payments. A Form 701 must also be filed if partial benefits are being paid at the time of the redemption or an advance payment results in a reduction or termination of the weekly rate. In February of each year, the Bureau runs a program which closes all open paying claims as of December 31 and reopens them on January 1 of the next year. Once that is done, an Open Claim Validation Report is sent to each carrier listing all claims that closed and reopened as well as those that could not be closed because of an error. This report should be used to verify that all claims on the report are still in open payment status and that the rate is correct. If not, the appropriate Form 701's should be filed. If partial benefits are being paid, the employee worked less than a 5 day work week, or the compensation rate is in error, a Form 701 must be filed. Form 701's which are filed to report payment of accrued benefits as a result of an order or agreement which cover multiple benefit periods should have the Report of Accrued Benefits worksheet (or a similar format) attached and include all available information: basis, benefit type, special payment, weekly rate, from and through dates and total amounts paid for each payment period. Interest payments, when applicable, should be reported on a separate line from the accrued benefit period(s) and include the special payment code, through date and total interest payment only. 1 American LegalNet, Inc. www.FormsWorkflow.com FILING INSTRUCTIONS FOR FORM 701 PART A This section must be completed in its entirety the first time the Form 701 is filed on a claim. On all subsequent filings, only items 1-3 and 17-21 are necessary. All other items do not need to be completed unless they have changed from the previous filing. Extreme care should be taken to ensure that all filings contain the same SSN and DOI that were first reported to the Bureau. #1. #2. #3. #4. #5. Social Security Number: Date of Injury: Employee Name: Date of Birth: Date of Death: 9 digit numeric. Must be complete date (MM/DD/YYYY). Employee's last name, first name and middle initial. Must be complete date (MM/DD/YYYY) If employee is deceased, enter complete date (MM/DD/YYYY). A Form 106 must also be filed. Complete address of employee, including number, street, city, state and zip code. Enter complete business name of employer (DBA, etc.) Enter 9 digit Federal ID number used by the employer listed in #10. This item only needs to be completed if the employer has multiple locations. A three digit code was assigned by the bureau for each different location, and carriers were notified of the codes in 1991. Enter the location code corresponding to the address where the claimant was employed at the time of injury. #6-9. Employee's Address: #10. #11. #12. Employer Name: Federal ID Number: Injury Location Code: #13-16. Employer Address: Complete address of employer, including number, street, city, state and zip code. #17. Carrier or Self-Insured Name: Enter complete name of insurance company or self-insured employer. A service agent name should not be reported in this field. NAIC or Self-Insured Number: 5 digit NAIC number and 3 digit group code should be reported for insurance companies and 8 digit self-insured ID number should be reported for self-insureds. Service Agent Name: Service Agent ID Number: Enter name of service agent handling claim, if applicable. The 3 digit service agent ID number assigned by the bureau must be reported if a service agent name is present in #19. Zip code of insurance carrier, self-insured employer or service company filing the form. The zip code will be used in conjunction with the carrier or service agent ID to identify the mailing address of the appropriate office where correspondence should be sent. Submitter's claim or file number, if applicable. This number will appear on all system generated correspondence. #18. #19. #20. #21. Zip Code of Issuing Office: #22. Carrier or Self-Insured Claim Number: 2 American LegalNet, Inc. www.FormsWorkflow.com #23. Date Carrier Received Notice of Injury: The date carrier received notice of injury. This information is required on the first filing of all voluntary payment cases to determine promptness of payment. If it is not present on the form, a system generated letter will be sent to the submitter. The date the first check was sent out on this claim. This date is required on the first filing of all voluntary payment cases to determine promptness of payment. If it is not present on the form, a system generated letter will be sent to the submitter. If the employer is continuing to pay wages while the compensability issue is being resolved or benefits are being coordinated under a wage continuation plan, the date first payment made should be the same as the from date in Part D. #24. Date First Payment Made: PART B The section must be completed in its entirety the first time the form is filed on a claim. On all subsequent fili
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