EMPLOYER'S BASIC REPORT OF INJURY Michigan Department of Workers’ Compensation Agency PO Box 30016, Lansing, MI 48909 An employer shall report immedia tely to the agen cy on Form WC-100 all injuries, including diseases, which arise out of and in the course of the employment, or on which a claim is made and result in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific losses. In case of death, an employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures. I. EMPLOYEE DATA 1. Social Security Number 2. Date of injury 3. Employee name (Last, First, MI) 4. Address (Number & Street) 5. City 8. Date of birth (MM/DD/YYYY) 10. Number of dependents 9. Sex Male 12. Tax filing status: A. Single 6. State 7. ZIP Code 11. Telephone number Female B. Single, Head of Household C. Married, Filing Joint D. Married, Filing Separate II. EMPLOYER/CARRIER DATA 13. Employer name 14. Federal ID Number 15. Injury location code 16. Mailing location code 17. UI number 20. City 19. Employer street address 18. Type of business (SIC/NAICS) 21. State 23. Insurance company name (if employer not self-insured) 22. ZIP code 24. Insurance company telephone number (if known) III. INJURY/MEDICAL DATA 25. Last day worked 26. Date employee returned to work (if applicable) 27. Did employee die? Yes 29. Injury city 30. Injury state 28. If yes, date of death No 31. Injury county 32. Did injury occur on employer's premises? 34. Time employee began work 35. Time of event Yes 33. Case number from OSHA/MIOSHA log a.m. No (If no, see item 53) If time cannot be determined, p.m. a.m. p.m. check here 36. What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. 37. How did the injury occur? Examples: “When ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during replacement” 38. Describe the nature of injury or illness 39. Part of body directly affected by the injury or illness 40. What object or substance directly harmed the employee? Examples: concrete floor, chlorine, radial arm saw. If this question does not apply to the incident, leave it blank. 41. Name of physician or other health care professional 42. Was employee treated in an emergency room? Yes 43. Was employee hospitalized overnight as an in-patient? No Yes No 44. If treatment was given away from the worksite, where was it given? (Include name, address, city, state and ZIP code of facility) IV. OCCUPATION AND WAGE DATA 45. Date hired 46. Total gross weekly wage (highest 39 of 52) 47. Number of weeks used 49. Occupation (Be specific) 50. Was employee a volunteer worker? 51. Was employee certified as vocationally handicapped? Yes 52. Date employer notified by employee V. PREPARER DATA No Yes 48. Value of discontinued fringes No 53. If temporary service agency, provide name/address of employer where injury occurred. I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE 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. 54. Preparer's name (Please print or type) 55. Preparer's signature 56. Telephone number 57. Date prepared Notice to employee: Questions or errors should be reported immediately to the individual listed above in space 54 WC-100 (Rev. 10/ ) Front American LegalNet, Inc. www.FormsWorkFlow.com If you are using this form as a replacement for the Form 301 to document the specifics of an injury or ill ness for purposes of compliance with the work-related injury and illness logging requirements, follow the instructions in Section A only. If you are using this form to report a workers’ compensation injury, follow the instructions in Section A and B. Section A This form can be used in lieu of the MIOSHA Form 301, Injury and Illness Incident Report. It is one of the first forms you must fill out when a re cordable work-related injury or il lness has occurred. Together with the Log of Work-Related Injuries and Illnesses (Form 300) and the accompanying Summary (Form 300A), these forms help the employer and MIOSHA develop a picture of the extent and severity of work-related incidents. Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out questions 1-9, 27-28, 33-45 and 54-57. According to Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974, Part 11, Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, you must keep this form on file for 5 years following the year to which it pertains. DO NOT mail this form to the Workers’ Compensation Agency unless it meets the conditions listed below in Section B. Section B You must complete all questions on this form if the injury or disease results in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b ) Death; (c) Specific lo ss. The original form must be mailed to the Workers’ Compensation Agency, P.O. Box 30016, Lansing, MI 48909. Authority: Completion: Penalty: Workers' Disability Compensation Act, 408.31(1)(3) Mandatory Workers' Disability Compensation Act, 418.631 WC-100 (Rev. 10/ LARA is an equal opportunit y employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. ) Back American LegalNet, Inc. www.FormsWorkFlow.com