Home | Contact Us | Sitemap | Admin | Login
Claims Forms - Wisconsin
English Spanish

First Report of Injury

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.

Wage Statement
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.

Mileage Reimbursement
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.

Medical Authorization
Authorization to obtain medical information.

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

Witness Statement
Form to be completed by a witness to the accident.

Fraud Investigation Notice  

Accident Investigation Report  

Michigan Office: toll free 800.262.4743 / Florida Office: toll free 877.925.9911 / email: info@mcim.com / terms of use