Michigan Notice of Compensation PaymentsMichigan Notice of Compensation Payments
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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

FILING # ________

PART A
1. Social Security Number

2. Date of Injury

3. Employee Name (Last, First, MI)

6. Employee Street Address

7. City

10. Employer Name
13. Employer Street Address

14. City

17. Carrier or Self-Insured Name

4. Date of Birth

5. Date of Death

8. State

9. ZIP Code

11. Federal ID Number

12. Injury Location Code

15. State

16. ZIP Code

18. NAIC or Self-Insured Number

19. Self-Insurer's Service Company Name
21. ZIP Code of Issuing Office

N/A

20. Service Company ID Number

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.

$

31. Tax Filing Status on Date of Injury

30. Second E