Michigan > Workers Comp
Notice Of Compensation Payments WC-701 - Michigan
| Notice Of Compensation Payments Form. This is a Michigan form and can be used in Workers Comp . |
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NOTICE OF COMPENSATION PAYMENTS Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 PART A 1. Social Security Number 2. Date of Injury 3. Employee Name (Last, First, MI) 4. Date of Birth 5. Date of Death FILING # ________ 6. Employee Street Address 7. City 8. State 9. ZIP Code 10. Employer Name 11. Federal ID Number 12. Injury Location Code N/A 13. Employer Street Address 14. City 15. State 16. ZIP Code 17. Carrier or Self-Insured Name 18. NAIC or Self-Insured Number 19. Service Company/TPA Name (if applicable) 20. Service Company/TPA ID Number 21. ZIP Code of Issuing Office 22. Carrier or Self-Insured Claim Number 23. Date Carrier Received Notice of Injury 24. Date First Payment Made PART B 25. Nature of Injury 26. Part of Body 27. Average Weekly Wage 28. Discontinued Fringes 29. Second Employer A.W.W. 30. Second Employer Discontinued Fringes $ 31. Tax Filing Status on Date of Injury $ 32. Last Day Worked $ 33. Number of Days in Work Week $ 34. Number of Dependents PART C 35. Reason for Filing 36. Weekly Compensation Base Rate $ 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported on line 37) $ PART D BASIS OF PAYMENT BENEFIT TYPE SPECIAL PAYMENT TOTAL WEEKLY RATE FROM THROUGH TOTAL AMOUNT PAID YEAR PAID TERMINATION REASON IF BASIS OF PAYMENT IS OTHER THAN "A" (VOLUNTARY PAYMENT) OR LINE 37 IS EQUAL TO "J" OR "K," ENTER ORDER # IF BENEFIT TYPE IS "C" (SPECIFIC LOSS), ENTER NUMBER OF WEEKS ________ AND EFFECTIVE DATE OF LOSS IF ANY FILING CODES ON THIS FORM REPRESENT "OTHER," PLEASE BE SPECIFIC 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. THIS IS TO CERTIFY THAT A COPY OF THIS FORM HAS BEEN MAILED OR GIVEN TO THE EMPLOYEE 39. Authorized signature 40. Person Handling Claim (Please Print) 41. Telephone Number 42. Date NOTICE TO EMPLOYEE: IF ANY OF THE ABOVE INFORMATION IS INCORRECT, PLEASE CONTACT THE INDIVIDUAL NAMED IN SPACE 40. WC-701 (Rev. 12/11) FRONT American LegalNet, Inc. www.FormsWorkFlow.com FILING CODES FOR FORM WC-701 31. TAX FILING STATUS A = SINGLE B = SINGLE/HEAD OF HOUSEHOLD C = MARRIED/FILING JOINT D = MARRIED/FILING SEPARATE 37. WEEKLY ADJUSTMENTS TO BASE RATE A = WAGE CONTINUATION OFFSET (-) B = SOCIAL SECURITY COORDINATION (-) C = PENSION OFFSET (-) D = UNEMPLOYMENT OFFSET (-) E = DISABILITY INSURANCE OFFSET (-) F = SELF INSURANCE OFFSET (-) G = OTHER BENEFIT COORDINATION (-) 38. REIMBURSEMENT BY A FUND* A = SILICOSIS, DUST DISEASE & LOGGING INDUSTRY COMPENSATION FUND B = SELF-INSURERS' SECURITY FUND C = VOCATIONALLY HANDICAPPED PROVISIONS/SIF D = OTHER 35. REASON FOR FILING A = COMMENCING BENEFITS B = CHANGE IN WEEKLY RATE C = TERMINATING BENEFITS D = COMMENCING AND TERMINATING BENEFITS E = REIMBURSEMENT BY A FUND F = REOPENING CLAIM G = REOPENING AND CLOSING CLAIM H = YEARLY REPORT OF PARTIAL PAYMENTS I = ERROR ON PREVIOUS FILING (ATTACH COPY) H = AGE 65 REDUCTION (-) I = COMPENSATION SUPPLEMENT (+) J = ADVANCE PAYMENT (-) K = 30% APPEAL ADJUSTMENT (-) L = SIF DIFFERENTIAL BENEFITS (+) M = DOUBLE COMPENSATION (+) N = THIRD PARTY OFFSET (-) O = 2 YEARS CONTINUOUS DISABILITY (+) P = RECOUPMENT OF OVERPAYMENT (-) Q = OTHER *DO NOT REPORT REIMBURSEMENTS RECEIVED AS A RESULT OF THE 70% OR DUAL EMPLOYMENT PROVISIONS. THIS INFORMATION WILL BE PROVIDED TO US BY THE SECOND INJURY FUND. PART D BASIS OF PAYMENT A B C D E F = VOLUNTARY PAYMENT = OPEN AWARD = CLOSED AWARD = STIPULATED AWARD = COMPROMISE = FORM 115 VOLUNTARY PAY PART D BENEFIT TYPE A = GENERAL DISABILITY B = PARTIAL WAGE LOSS C = SPECIFIC LOSS D = PERMANENT TOTAL E = DEATH F = OTHER PART D SPECIAL PAYMENT A = ACCRUED BENEFITS B = INTEREST C = 30% APPEAL ADJUSTMENT D = OTHER PART D TERMINATION REASON A = RETURNED TO WORK WITH NO WAGE LOSS B = RECOVERED FROM DISABILITY (ATTACH MEDICAL) C = AWARD REVERSED D = END OF SPECIFIC LOSS E = CLAIMANT DECEASED (ATTACH DEATH CERTIFICATE) F = CLOSING OUT WEEKLY DUE TO REDEMPTION G = CLOSING OUT WEEKLY DUE TO ADVANCE PAYMENT H = OTHER PART E COORDINATION OF BENEFITS SECTION 1-5 1. PENSION A. WEEKLY BENEFIT AMOUNT B. 80% AFTER-TAX AMOUNT OF (A) 2. WAGE CONTINUATION 3. DISABILITY INSURANCE 4. SELF INSURANCE 5. OTHER x 1.25 C. 100% AFTER-TAX AMOUNT D. FICA TAX* E. STATE INCOME TAX* F. % EMPLOYER CONTRIBUTION G. INCOME TO BE COORDINATED** x 1.25 x 1.25 x 1.25 x 1.25 * Does not apply in all cases. If applicable, include the value of FICA and state income tax using the figures provided in the back of the agency's rate tables corresponding to the year of injury. ** Line G = (Line C + D + E) x Line F. (This figure should appear in Section 37 with the appropriate adjustment code.) SECTION 6 SOCIAL SECURITY A. MONTHLY OLD-AGE BENEFIT B. WEEKLY OLD-AGE BENEFIT (ABOVE AMOUNT ÷ 4.33) C. TOTAL AMOUNT OF SOCIAL SECURITY BENEFITS TO BE COORDINATED (50% OF LINE B) $ $ $ (ENTER WITH CODE "B" IN SECTION 37) SECTION 7 UNEMPLOYMENT COMPENSATION A. B. NUMBER OF WEEKS AWARDED BEGINNING DATE OF UNEMPLOYMENT COMPENSATION $ SCHEDULED EXPIRATION DATE (ENTER WITH CODE "D" IN SECTION 37) C. TOTAL WEEKLY UNEMPLOYMENT COMPENSATION BENEFITS LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-701 (Rev. 12/11) BACK Authority: Completion: Penalty: Workers' Disability Compensation Act, R408.31(6a-d) Mandatory Workers' Disability Compensation Act, 418.631; 418.801 American LegalNet, Inc. www.FormsWorkFlow.com
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