MCIM Claim Forms - Michigan
First Report of Injury
Informe Basico de Lesión Del Empleador
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.
Informe Basico de Lesión Del Empleador
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
Declaración del Salario
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.
Declaración del Salario
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
Petición de Reembolso del Kilometraje
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.
Petición de Reembolso del Kilometraje
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.
Fringe Benefit
Información de los Beneficios Complimentarios
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.
Información de los Beneficios Complimentarios
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.
