NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for submitting this form by email.

Please report injuries to MCIM as soon as possible.

This form is necessary in all lost time cases where wages will be paid to the injured worker. The Workers' Compensation Act requires that we have 52 weeks of prior wage information whenever possible to determine the rate at which they will be paid.

This form is included for the worker’s convenience in requesting reimbursement for mileage incurred traveling to medical appointments in connection with the injury. Injured Worker’s can submit thoroughly completed forms to their examiner.

Authorization to obtain medical information.

Initial Form to be completed by the injured worker.

If fringe benefits are discontinued at any time while an injured worker is off work we must add any discontinued fringes into their weekly compensation rate.