AGREEMENT TO REDEEM LIABILITY Michigan Department of Labor & Economic Growth Workers’ Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909 Plaintiff Name Social Security Number Address Employer Carrier The above parties represent as follows: was an employee of and on or about the employee received an injury arising out of and in the course of his/her employment and that six (6) months has elapsed since the date of injury and that: (In the above space state fully the following facts: total amount of compensation paid to date, the present disability of the employee, and the reasons for desiring a redemption of liability.) WHEREFORE, it is agreed to by and between the parties that the Agency may enter an order in this cause providing that the sum of shall be forthwith paid by the employer/carrier to and that upon such payment the liability of the employer/carrier for the payment of compensation for said injury shall be redeemed in accordance with Sections 418.835, 418.836 and R408.39 of the Workers’ Disability Compensation Act. Dated Employee or dependent(s) Attorneys for employee or dependent(s) Employer (if self-insured) or Insurance Company Attorneys for Employer (if self-insured) or Insurance Company All Agreements to Redeem Liability must be submitted on blanks furnished by the Agency. The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. WC-556 (Rev. 5/05) American LegalNet, Inc. www.USCourtForms.com