800.262.4743

PO Box 80440
Lansing, Michigan 48908-0440

Claims Forms - Michigan
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First Report of Injury
Please report injuries to MCIM as soon as possible.

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

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

Medical Authorization
Authorization to obtain medical information.

Employee Questionnaire
Initial Form to be completed by the injured worker.

Fringe Benefit
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.