FUNDS ADMINISTRATION USE ONLY APPLICATION FOR REIMBURSEMENT MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS FUNDS ADMINISTRATION P.O. Box 30182, Lansing, MI 48909 FUNDS ADMINISTRATION 1. 2. 3. 4. 5. 6. Total & Permanent Disability Provision - Section 521 (1) (2) 70% Reimbursement Provision - Section 862 Two Years of Continuous Disability Provision - Section 356 (1) Vocationally Handicapped Provision - Section 925 Dual Employment Provision - Section 372 Silicosis, Dust Disease and Logging Industry Compensation Fund - Section 531 REQUEST NUMBER CARRIER FILE NUMBER COMPLETE THIS SECTION FOR ALL FUNDS Applications for reimbursement should be submitted every six months unless otherwise indicated. EMPLOYEE NAME (Last, First, Middle) EMPLOYEE ADDRESS NAME OF EMPLOYER CARRIER (Insurance Company or Self-Insured Employer)* CARRIER FEDERAL I.D. NUMBER (Street Number and Name) SOCIAL SECURITY NUMBER CITY INJURY DATE STATE ZIP CODE BIRTH DATE PHONE NUMBER ( ) EMPLOYER ADDRESS SERVICE COMPANY OR TPA (If Applicable) EMAIL ADDRESS PHONE NUMBER ( ) CONTACT PERSON PAYMENT ADDRESS (*To receive payment carrier must be registered with the State of Michigan, Budget Office. Register at http://michigan.gov/cpexpress or 1-888-734-9749. AVERAGE WEEKLY WAGE DISCONTINUED FRINGES TAX FILING STATUS (AT DOI) CARRIER/EMPLOYER PRESENT WEEKLY COMPENSATION RATE Benefits Calculated on_____Day Week IS THERE A THIRD PARTY CLAIM $ $ $ YES (If YES, provide pertinent information on claim) NO DEPENDENTS SPOUSE________________________ CHILDREN (Name and Date of Birth) ____________________________ (Name and Birth Date) __________________________ REASON FOR CHANGE (Name and Date of Birth) _______________________ (Name and Date of Birth) _____________________ HAS BASIC BENEFIT CHANGED or TERMINATED DURING PERIOD? YES NO EFFECTIVE DATE:___________________________ Death Date of Death_________________ (Attach Death Certificate) HAS EMPLOYEE BEEN GAINFULLY EMPLOYED DURING PERIOD COVERED BY THIS REIMBURSEMENT? YES - Attach records confirming employment with evidence of weeks and hours worked, and earnings statement. (Provide evidence on value of fringe benefits if applicable) NO - Attach information received verifying continuing disability and current activities Age Reduction Benefit Coordination Dependency Change (Attach Verification) Employments Unemployment Compensation Other__________________________________ (1) COMPLETE this section when requesting reimbursement from the Second Injury Fund - TOTAL AND PERMANENT DISABILITY PROVISION: Weekly differential benefits paid on Fund's behalf: thru , weeks at $ = $ _________________________________ ____ thru ______ , weeks at $ = $__________________________________ $ _________________________________ TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT (submit after all appeals are final) (2) COMPLETE this section when requesting reimbursement from the Second Injury Fund - 70% REIMBURSEMENT PROVISION: (a) Attach decision by Board of Magistrates ordering payment and all subsequent orders and decisions including order reversing/modifying decision. YES NO (b) Confirmation that ALL appeals are final (c) Attach copy of all 701's. (d) Provide written verification of dependents during appeal period. NOTE: Request reimbursement for medical expenses paid under section 862(2) by completing WCA Form 271. 70% Benefits Paid on Appeal: thru thru Total 70% Benefits Paid: Minus: Dollar Value of final award, including interest (if applicable): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT FA 112 (Revised 01/2014) American LegalNet, Inc. www.FormsWorkFlow.com , , weeks at $ weeks at $ = $___________________________________ = $ ___________________________________ $____________________________________ - $ ____________________________________ $ ____________________________________ (3) COMPLETE this section when requesting reimbursement from the Second Injury Fund - TWO YEARS OF CONTINUOUS DISABILITY PROVISION Reimbursement due on a quarterly basis. Weekly benefit rate paid on Second Injury Fund's behalf: thru , thru REIMBURSEMENT FOR REDEMPTION PAYMENT , TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT weeks at $ weeks at $ = $ ______________________________ = $ _____________________________ $_______________________________ $_______________________________ (4) COMPLETE this section when requesting reimbursement from the Second Injury Fund - VOCATIONALLY HANDICAPPED PROVISION Vocational rehabilitation benefits under section 319 are reimbursable from the date of injury _ thru _____________________ thru Total weekly benefits paid on Fund's behalf: Medical expenses paid during period (attach copies of bills and reports): Vocational rehabilitation costs paid during period (attach copies of bills and reports): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT , , _ weeks at $ weeks at $ = $ ______________________________ = $ _______________________________ $______________________________ __ $________________________________ $________________________________ $ _______________________________ 5) COMPLETE this section when requesting reimbursement from the Second Injury Fund - DUAL EMPLOYMENT PROVISION Reimbursement due on a quarterly basis NOTE: (1) Include forms 100 & 701. Attach WAGE RECORDS (by pay period ending dates) for all employers. (2) Attach DOCUMENTATION OF DISABILITY, i.e., medical records. (3) Complete only Section II below on continuous reimbursement cases, otherwise, complete both. INSTRUCTION FOR COMPLETION OF SECTION I: (1) 3 or more employers? Use separate sheet to provide information (employer, address, wages) required (2) Carry out apportionment percentages to one hundredths of a percentage (xx.xx% or .xxxx) (3) Average weekly wage with each employer is based upon number of weeks worked at that employer I. Name of Employer: Place of Injury $ Name of Other Employer Address: Phone: Has there been a return to work with any employer YES NO If yes, complete section across $ WAGES # OF WEEKS USED AVERAGE __ _ (A) � ___________ = $ � = $ _____________________________ Total average weekly wages From separate sheet (if applicable): $ ______________________________ Total: $ _ __ (B) Employer __ Date: _________________________ Employer __ Date:_________________________ Employer_______________________Date:_________________________ _ _ (B) = ____ (C) = __________ % (C) % (D) II. Carrier Apportionment % of liability: $ (A) � $ __ Dual Employment Provision's % of liability: 100% If (D) is less than 20% the DUAL EMP