Michigan Supplemental Report of Fatal Injury
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SUPPLEMENTAL REPORT OF FATAL INJURY
Michigan Department of Licensing and Regulatory Affairs
Workers' Compensation Agency
PO Box 30016, Lansing, MI 48909

THIS REPORT IS TO BE FILED BY THE EMPLOYER IMMEDIATELY AFTER THE DEATH OF AN INJURED EMPLOYEE.
I. DECEASED EMPLOYEE
1. Social Security Number

2. Date of Injury

3. Date of Death

6. City

7. State

4. Name (Last, First, Middle Initial)
5. Street Address

II. EMPLOYER DATA
9. Employer Name

8. ZIP Code

10. Federal I.D. Number

11. Street Address

12. City

13. State

14. ZIP Code

15. Amount of Burial Expenses Paid (If Not Previously Reported)

$

III. DEPENDENTS OF EMPLOYEE
16.

Name

20. Employer’s Signature

18.

17.

Date of Birth

Relationship to Deceased

(Spouse, Child, or Other - Please Specify Other)

21. Title

LARA is an equal opportunity employer/program. Auxiliary aids, services and
other reasonable accommodations are available upon request to individuals
with disabilities.
WC-106 (10/11)

19.

Extent of De