| Title |
Last Updated |
| Subpoena For Production Of Records And Or Witness Subpoena |
June 19, 2019 |
| Opinion Order |
June 19, 2019 |
| Letter Of Credit-Memorandum Of Understanding |
June 15, 2018 |
| Annual Medical Payment Report |
March 18, 2016 |
| Workers Disability Compensation Self-Insurer Application |
November 3, 2015 |
| Workers Compensation Agency Service Company Application |
November 3, 2015 |
| Self-Insurer Request To Add Or Delete Subsidiary Affiliate |
November 3, 2015 |
| Self Insurers Claims Transfer Agreement |
November 3, 2015 |
| Self Insurer Letter Of Credit Information |
November 3, 2015 |
| Michigan Certificate Of Specific Or Aggregate Excess Liability Insurance (Self Insurer) |
November 3, 2015 |
| Group Self-Insurer Application |
November 3, 2015 |
| Authorization To Disclose Confidential Workers Compensatin Information |
November 3, 2015 |
| Freedom Of Information Request |
November 3, 2015 |
| Application For DEG User Account |
November 3, 2015 |
| Application For Certification Of Carriers Professional Health Care Review Program |
November 3, 2015 |
| Application For Authorization For Servicing Agent DEG User Account |
November 3, 2015 |
| Application For Agency Approval As A Rehabilitation Facility |
November 3, 2015 |
| Self Insurer Application |
July 28, 2015 |
| Michigan Continuous Surety Bond (Group Of Self Insurers) |
July 28, 2015 |
| Application For Reimbursement From The Medical Benefits Fund |
July 28, 2015 |
| Application For Reimbursement (From Funds Administration) |
July 28, 2015 |
| Voluntary Payment Form |
July 15, 2015 |
| Michigan Continuous Surety Bond (Self Insurer) |
April 13, 2015 |
| Carriers Explanation Of Benefits |
January 31, 2014 |
| Application For Mediation Or Hearing-Form B |
January 23, 2014 |
| Insurers Notice Of Name Or Address Change |
November 17, 2013 |
| Notice Of Compensation Payments |
November 17, 2013 |
| Employees Report Of Claim |
July 29, 2013 |
| Notice Of Termination Of Liability |
July 29, 2013 |
| Employers Basic Report Of Injury |
July 29, 2013 |
| Notice Of Dispute |
July 29, 2013 |
| Instructions For Notice Of Compensation Payments Form With Examples |
July 29, 2013 |
| Insurers Notice Of Issuance Of Policy |
July 29, 2013 |
| Application For Mediation Or Hearing-Form A |
July 11, 2013 |
| Workers Settlement Statement |
January 16, 2013 |
| Report On Rehabilitation |
January 16, 2013 |
| Application For Reimbursement From The Compensation Supplement Fund |
January 16, 2013 |
| Application For Advance Payment |
January 16, 2013 |
| Agreement To Redeem Liability |
January 16, 2013 |
| Supplemental Report Of Fatal Injury |
November 22, 2011 |
| Notice Of Termination Of Membership |
November 22, 2011 |
| Group Self-Insurer Application Packet |
November 22, 2011 |
| Self-Insured Group Notice Of Termination Of Membership |
September 22, 2011 |
| Self-Insured Group Notice Of Acceptance Of Membership |
September 22, 2011 |
| Request For Compliance Hearing |
February 1, 2010 |
| Vocational Rehabilitation Provider Professional Disclosure Statement |
April 7, 2009 |
| Workers Disability Compensation Group Self Insurer Application |
February 19, 2009 |
| Work History Work Qualifications And Training Disclosure Questionnaire |
November 13, 2008 |
| Employer Disclosure Questionnaire |
November 13, 2008 |
| Affidavit In Support Of Redemption (Settlement) Agreement |
February 27, 2008 |
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