CARRIER'S RESPONSE Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 Social Security Number Date of Birth Employee Name Employee Address (Street No. and Name) Employee City State ZIP Code Date(s) of Injury Insurance Company/TPA Claim Number Employer Insurance Company or TPA (If self-insured) Employer Address (Street No. and Name) Insurance Company Address (Street No. and Name) City State ZIP Code City State ZIP Code Federal ID Number NAIC or Self-Insurance Number 1. Do you dispute that the injury or disability is work related? 2. Do you dispute that the claimant is disabled? 3. List reasons supporting your position in the space provided. Yes Yes No No 4. Have you had the claimant medically examined in connection with this claim? If yes, give name and address of individual who performed the examination. Yes No 5. Do you certify that to the best of your knowledge all existing medical records of the carrier or employer contained in your file that are relevant to this claim have been furnished to the claimant Yes No and/or the claimant's attorney? Claims person/attorney to whom correspondence should be sent Attorney ID Number (If applicable) Claims office/attorney address Telephone No. (Include area code) Preparer Signature Date LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Authority: Workers' Disability Compensation Act, Section 418.222 Completion: This form is to be submitted by the carrier within thirty (30)days after the carrier's receipt of a completed Application for Mediation or Hearing. Penalty: Failure to complete shall prohibit that party from proceeding. American LegalNet, Inc. www.FormsWorkFlow.com WC-251 (4/12)