Michigan Employer's Basic Report of InjuryMichigan Employer's Basic Report of Injury
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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)
8. Date of birth (MM/DD/YYYY)

9. Sex
Male

12. Tax filing status:

A. Single

5. City

6. State

7. ZIP Code

10. Number of dependents

11. Telephone number

Female

B. Sing