APPLICATION FOR ADVANCE PAYMENT Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 INSTRUCTIONS TO APPLICANT: Only applicants who are currently receiving workers' compensation benefits may file this form. It should be completed and mailed to the above address. No action will be taken on this application unless you answer all questions in Section 1 (numbers 1 through 14) and sign your name under "Applicant Signature." SECTION 1: TO BE COMPLETED BY APPLICANT 1. Social Security Number 2. Date of Injury 3. Employee Name (Last, First, Middle Initial) 4. Employer Name 5. Insurance Company Name (if applicable) 6. Applicant Name (if other than employee) 7. Relationship to Employee 8. Applicant Street Address 9. City, State, ZIP Code 10. Amount of Advance Requested 11. If amount is part of the remaining weekly benefits due, take repayment from the 12. If amount is from next payments due, repay by reducing weekly rate by $ Next Last Payments Due $ 13. The employer or its insurance carrier has the right to 10% interest per year on the advance you are requesting. If they request that this discount be taken, do you still want the advance payment to be approved? Yes No 14. Clearly state your reason(s) for requesting the advance payment. Applicant Signature Date Attorney Name (if applicable) Attorney ID # P- SECTION 2: TO BE COMPLETED BY CARRIER Does the carrier agree with the terms of the advance payment request? Is the discount requested? Yes Carrier Signature No Carrier Name Yes Date No Authority: Workers' Disability Compensation Act, 418.835; 418.837 Completion: Voluntary Penalty: None LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-108 (Rev. 11/11) American LegalNet, Inc. www.FormsWorkFlow.com