APPLICATION FOR REIMBURSEMENT FROM THE MEDICAL BENEFITS FUND Michigan Department of Licensing and Regulatory Affairs Workers’ Compensation Agency PO Box 30016, Lansing, MI 48909 Type or print clearly. Incomplete applications shall be returned. Employee Name (Last, First, MI) Social Security Number Address (Street Number and Name) Date of Injury Date of Birth City State ZIP Code Employer Name Insurance Carrier or Service Company Address (Street Number and Name) Address (Street Number and Name) City State ZIP Code City Federal ID Number State ZIP Code NAIC or Self-insurance Number Is there a health carrier covering this employee? Yes No If yes, please indicate the name of that carrier: Please state the reason these bills have not been submitted to the health carrier for payment: Period covered by this request FROM Month Day THROUGH Year Month Day Year Total Reimbursement Amount Requested $ A COPY OF THE MAGISTRATE’S ORDER AND ALL SUBSEQUENT APPELLATE ORDERS MUST ACCOMPANY THIS REQUEST. A COPY OF ALL ORIGINAL INVOICES (INCLUDING DATE OF SERVICE, NAME OF THE HEALTH CARE PROVIDER AND DIAGNOSIS) AND PROOF OF PAYMENT SHOWING AMOUNT AND DATE PAID MUST BE ATTACHED TO THIS REQUEST. Before you sign this request for reimbursement, please be sure all attachments are included and the form is complete. Name of Authorized Representative (Please print) Title Signature of Authorized Representative Telephone Number (Include area code) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Authority: Completion: Penalty: WC-271 (4/11) Date Workers’ Disability Compensation Act 418.862(2). Voluntary None American LegalNet, Inc. www.FormsWorkFlow.com