EMPLOYEE’S REPORT OF CLAIM Michigan Department of Labor & Economic Growth Workers’ Compensation Agency P.O. Box 30016, Lansing, MI 48909 1. Social Security Number 2. Date of Injury 3. Date of Birth (MM/DD/YYYY) 5. Employee Name (Last, First, MI) 6. Employer Name 7. Employee Street Address 4. Employee Telephone Number 8. Employer Street Address 9. Employee City 10. State 11. ZIP Code 12. Employer City 13. State 14. ZIP Code 15. Describe the type of injury and explain how it happened. (If a medical report is available, please attach a copy.) 16. Are you making a claim for payment of medical expenses? Yes No 17. Last Day Worked If yes, please attach a copy of medical bill(s) if available. 18. Have you gone back to work? Yes No 19. Was the injury reported to your employer? If yes, date of return __________/__________/__________ Yes No If yes, date reported __________/__________/__________ Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits. 20. Employee Signature 21. Date of this report OFFICE USE ONLY Carrier Name The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. Authority: Workers’ Disability Compensation Act, 408.31(4) Completion: Voluntary Penalty: None WC-117 (Rev. 9/05) American LegalNet, Inc. www.FormsWorkflow.com