COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. FORM 112 APPLICATION FOR REIMBURSEMENTNo. : Index Michigan Department of Consumer & Industry Services Bureau of Workers’ & Unemployment Compensation : Funds Administration Calendar 7201 W. Saginaw Hwy., Suite 110, Lansing, MI 48917 FUNDS ADMINISTRATION 1. 2. 3. 4. 5. 6. : No. JUDICIAL SUBPOENA FUNDS ADMINISTRATION USE ONLY Plaintiff(s) Total & Permanent Disability Provision - Section 521 (1) (2) -against70% 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 Defendant(s) : . . . . . .Applications. for .reimbursement.should .be. submitted. every.six months unless otherwise indicated. ......... .. ........... ..... . ....... .... .. EMPLOYEE NAME (Last, First, Middle) SOCIAL SECURITY # | EMPLOYEE ADDRESS (Street No. and Name) (City) INJURY DATE | (State) | (Zip) BIRTH DATE | | | (Phone Number) THE PEOPLE OF THE STATE OF NEW YORK NAME OF EMPLOYER EMPLOYER ADDRESS TO INSURANCE CO. OR SELF-INSURED EMPLOYER FEDERAL I.D. NUMBER SERVICE COMPANY OR TPA (If Applicable) CONTACT PERSON TELEPHONE NUMBER GREETINGS: PAYMENT ADDRESS WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable atDEPENDENTS the Court Spouse Tax filing status at time of injury located at CountyWeekly Wage of Claimant’s Average $ Birth any Carrier/Employer Present in room , on the day of , 20 , at Children o'clock in the noon, and atdate recessed Weekly Compensation Ratedate, to testify and give evidence as a witness in this action on the part of the $ or adjourned Benefits calculated on a day week IS THERE A THIRD PARTY CLAIM? YES If YES, provide pertinent information on claim. NO Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party onof Benefitbehalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a whose Change: YES NO Date Attach 701 Reason for Change: Age Reduction Benefit Coordination result of your failure to comply. Employment Dependency Change (attach verification) Unemployment Compensation Other HAS BASIC BENEFIT CHANGED DURING PERIOD? 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 Witness, , one of the Justices of the benefits if applicable) Honorable NO Attach information received verifying continuing disability and current activities Court in County, day of , 20 (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 $ =$ (Attorney must sign above and type name below) thru , weeks at $ TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT =$ $ (2) COMPLETE this section when requesting reimbursement from the Second Injury Fund - 70%Attorney(s) for PROVISION: (submit after all appeals are final) REIMBURSEMENT (a) Decision by Board of Magistrates ordering payment and order reversing/modifying decision: (b) Confirmation that ALL appeals are final YES NO (c) Copy of all 701s indicating payments (d) Written verification of dependents during appeal period NOTE: Request reimbursement for medical expenses paid under section 862(2) by completing BWC form 271. Office and P.O. Address 70% Benefits Paid on Appeal: thru , weeks at $ =$ thru Total 70% Benefits Paid: Minus: Dollar Value of final award, including interest (if applicable): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT BWC-112 (Revised 05/02) , weeks at $ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: =$ $ — $ $ American LegalNet, Inc. www.USCourtForms.com COURT (3) COMPLETE this section when requesting reimbursement from the Second Injury Fund - TWO YEARS OF CONTINUOUS DISABILITY PROVISION COUNTY . Reimbursement.due .on .a.quarterly.basis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OF . . . . . . . . : Weekly benefit rate paid on Second Injury Fund’s behalf: thru thru TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT Index No. : weeks Calendar No. at $ , , weeks at $ : Plaintiff(s) =$ =$ $ JUDICIAL SUBPOENA (4) COMPLETE this section when requesting reimbursement from the Second Injury Fund - VOCATIONALLY HANDICAPPED PROVISION - Vocational -againstrehabilitation benefits under section 319 are reimbursable from the date of injury : thru thru , , weeks at $ =$ =$ $ $ $ $ : weeks at $ 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 Defendant(s) : : ...................................................... (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 for all employers. (2) Attach DOCUMENTATION OF DISABILITY, i.e., medical THE PEOPLE OF THE STATE OF NEW YORK records. (3) Complete only Section II on continuous reimbursement cases, otherwise, complete both. INSTRUCTION FOR COMPLETION OF SECTION I: TO (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 WAGES GREETINGS: NUMBER OF WEEKS USED $ ÷ AVERAGE = $ (A) Name of Other Employer WE COMMAND YOU, that all business and excuses being laid aside, you and each of = $attend before you $ ÷ , Honorable at the Total average weekly wages Court From separate sheet (if applicable): $ located at County of Phone: $ (B) in room , on the day of , 20 , at o'clock in the noon, and at any recessed or been a return to work testify and give YES a Has there adjourned date, towith any employer evidence asNOwitness in this action on the part of the Employer Date: the Address: If yes, complete section across: > Date: Employer II. Employer Date: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Carrier/Employer Apportionment % of liability: $ (A) ÷ $ (B) = % (C) the party on whose behalf this penalty of- $50 and all damages sustained as a (C) = % (D) Dual Employment Provision’s % of liability: subpoena was issued for a maximum 100% result of your failure to comply. If (D) is less than 20%, the DUAL EMPLOYMENT PROVISION has no liability pursuant to Section 372. Workers’ Compensation Benefits paid during period: Witness, Honorable Court in County, , one of the Justices of the day of thru thru , 20 , weeks at $ =$ , weeks at $ =$ Total weekly benefits paid during this reimbursement period: TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT $ (Attorney must sign above and type name below) (E) x (E) % (D) = $ (6) COMPLETE this section when requesting reimbursement from the SILICOSIS & DUST DISEASE FUND or LOGGING INDUSTRY COMPENSATION FUND Attorney(s) for Weekly benefits paid during this period: thru thru thru , , , Total benefits paid during period Minus threshold on first reimbursement only Apportionment percentage due (SDDF only): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT: weeks at $ weeks at $ weeks at $ Office and P.O. Address =$ =$ =$ $ x $ SIGNATURE OF AUTHORIZED REPRESENTATIVE TITLE Authority: Completion: Penalty: Telephone No.: Facsimile No.: The DepartmentE-Mail & Industry Services will not discriminate against any individual or group because of race, of Consumer Address: sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, Mobile Tel. No.:Disabilities Act, you may make your needs known to this agency. writing, hearing, etc. under the American's with Workers Disability Compensation Act R408.46 Voluntary None DATE SUBMITTED American LegalNet, Inc. www.USCourtForms.com %