EMPLOYEE’S REPORT OF CLAIM
Michigan Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
P.O. Box 30016, Lansing, MI 48909
1. Social Security Number
2. Date of Injury
3. Date of Birth (MM/DD/YYYY)
5. Employee Name (Last, First, MI)
6. Employer Name
7. Employee Street Address
8. Employer Street Address
9. Employee City
11. ZIP Code
12. Employer City
4. Employee Telephone Number
14. ZIP Code
15. Describe the type of injury and explain how it happened. (If a medical report is available, please attach a copy.)
16. Are you making a claim for payment of medical expenses?
17. Last Day Worked
If yes, please attach a copy of medical bill(s) if available.
18. Have you gone back to work?
If yes, date of return __________/__________/__________
19. Was the injury reported to your employer?
If yes, date reported __________/__________/__________
Making a false or fraudulent statement for the purpo