CLAIM/CROSS-CLAIM FOR REVIEW Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016 Lansing, Michigan 48909 Please check one: Claim for Review Cross-Claim for Review INSTRUCTIONS: SEE REVERSE SIDE 1. Social Security Number 3. Employee Street Address 7. Party Filing this Appeal 2. Employee Name (Last, First, Middle Initial) 4. City 5. State 6. ZIP Code Plaintiff 8. Employer Name Carrier or Self-Insured Employer (If Uninsured) Other (Specify) 9. Federal ID Number 11. NAIC or Self-Insured Number 10. Carrier or Self-Insured Name 12. Order Number 13. Type of Order Being Appealed (Check Only One) A COPY OF THE ORDER BEING APPEALED MUST BE ATTACHED D. E. F. Interlocutory Decision Redemption Order Advance Payment Order G. H. I. Vocational Rehabilitation Order Attorney Fees Other A. B. C. Decision on Merits Dismissal of Petition Director's Order 14. Basis of Claim. This application for review of claim is based on the following grounds: 15. Transcript Required? If no, reason: Yes No Date Transcript(s) Ordered If no, reason: Hearing Dates: 16. Number of Transcript(s) 17. Proof of Service Attached? Yes No I8. If representing yourself, please complete this section. Signature Telephone Number Date Signed 19. Legal counsel, if obtained, must complete this section. Signature Attorney ID Number Date Signed PLARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-262 (Rev. 4/12) Front American LegalNet, Inc. www.FormsWorkFlow.com Authority: Completion: Penalty: Workers' Disability Compensation Act 418.101 et seq. Voluntary Order Stands INSTRUCTIONS FOR COMPLETING WC-262 A Claim for Review must be filed within 30 days of the mailing date of the magistrate's order, or the order stands as final. However, all redemption, advance payment, attorney fee, and director's orders must be filed within 15 days, or the order stands as final. The completed form should be sent to the address on the front of this form along with a copy of the order being appealed. A separate Claim for Review must be filed for each order being appealed. If you require more space than is provided on this form, use a separate sheet of paper to provide the additional information and include the employee's name and social security number. Please note on the application that the required information is on an attached sheet. 1. Social Security Number 2. Name of Employee 3-6. Employee Address 7. Party filing this appeal 8. Employer Name 9. Federal ID Number 10. Carrier or Self-Insured Name 11. NAIC or Self-Insured Number 12. Order Number 13. Type of Order Being Appealed 14. Basis of Claim 15. Transcript Required/Reason 16. Number of Transcript(s)/ Date Transcript(s) Ordered Enter the social security number of the injured employee. Enter the complete name of the injured employee. Enter the street address, city, state and ZIP code of the injured employee. Indicate which party is filing this appeal. If other, please specify. Only one box should be checked. Enter the name of the employer involved in the appeal. Enter the FEIN (Federal Employer ID Number) of the employer listed in Item 8, if known. Enter the name of the insurance carrier or self-insured employer involved in this appeal. Enter the NAIC or self-insured number of the carrier or self-insured listed in Item 10, if known. Enter the 9-digit number located at the top of the order which is being appealed. The first six digits represent the mailed date. Indicate which type of order is being appealed. If Box A, B, C, or D is checked, any future filings on this appeal must be sent to the Workers' Compensation Appellate Commission, PO Box 30468, Lansing, MI 48909. Indicate the grounds upon which this Claim for Review is based. Indicate whether transcript(s) are required. If no, specify the reason. Indicate the number of transcript(s) and the date they were ordered (if required). Also indicate the hearing date(s) in which testimony was taken. Indicate whether proof of service is attached. If not attached, specify the reason. If representing yourself, please sign and date this form and provide telephone number. If legal counsel is obtained, the attorney must sign and date this form and provide attorney ID number. 17. Proof of Service Attached 18. Applicant Signature 19. Attorney Signature WC-262 (Rev. 4/12) Back American LegalNet, Inc. www.FormsWorkFlow.com