Michigan Application For Reimbursement From The Compensation Supplement Fund
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APPLICATION FOR REIMBURSEMENT FROM THE
COMPENSATION SUPPLEMENT FUND
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
PO Box 30016, Lansing, MI 48909
Initial (For Quarter)
Corrected

Carrier File No.

Employer Name (Type or print)
Employee Name (Last, First, MI)
Employee Street Address
Social Security Number

Date of Injury (MM-DD-YYYY)

City

State

Average Weekly Wage on Date of Injury

Date of Birth (MM-DD-YYYY)

Name of Insurance Company or Self-Insured

Carrier I.D. Number

Carrier Address (Street)

City

Federal Employer I.D. Number

Reimbursement
Requested For:

Date to

(MM-DD-YYYY)

(MM-DD-YYYY)

Weeks

State

Zip Code

Weekly Comp. Rate on Jan. 1, 1982
Quarter ___________ Calendar Year _____________

Compensation Paid
Date from

Zip Code

Days

Supplement
Percentage

Weekly Second Injury
Fund Differential
Benefits Paid

Weekly
Compensation
Supplement

Total
Reimbursement
Requested

Total
Supplement
Paid

$ ___________

Date of