GENERAL INFORMATION – Form 701 The Form BWC-701 (hereafter referred to as Form 701) is used to report to the Bureau payment of weekly compensation benefits made to the employee. Attorney fees, rehabilitation costs, medical expenses, etc. should not be reported on the form. Burial expenses must be reported by the employer on Form BWC-106 or a receipt of payment will be requested. The filing number should always be #1 the first time the Form 701 is submitted for a claim, and then increase sequentially for subsequent filings. It is critical that all subsequent filings contain the exact SSN and DOI that was reported on the first filing. If this information was previously reported in error, the correction(s) should be clearly marked on the form. Friend of the Court payments should not be reported to the Bureau. All Bureau orders have a nine digit number written in the upper right hand corner consisting of the mailed date and a three digit sequential number. All Form 701's that are filed pursuant to an award (basis of payment anything other than “A”) should have the order number included in the space provided below section D. Redemptions and advance payments do not need to be reported on a Form 701. If the redemption involves a claim which is in payment status, the system will automatically close out the weekly payments assuming that the weekly rate, date of injury and carrier listed on the redemption order match the information on the latest Form 701. If not, a Form 701 must be filed closing out the weekly payments. A Form 701 must also be filed if partial benefits are being paid at the time of the redemption or an advance payment results in a reduction or termination of the weekly rate. In February of each year, the Bureau runs a program which closes all open paying claims as of December 31 and reopens them on January 1 of the next year. Once that is done, an Open Claim Validation Report is sent to each carrier listing all claims that closed and reopened as well as those that could not be closed because of an error. This report should be used to verify that all claims on the report are still in open payment status and that the rate is correct. If not, the appropriate Form 701's should be filed. If partial benefits are being paid, the employee worked less than a 5 day work week, or the compensation rate is in error, a Form 701 must be filed. Form 701's which are filed to report payment of accrued benefits as a result of an order or agreement which cover multiple benefit periods should have the Report of Accrued Benefits worksheet (or a similar format) attached and include all available information: basis, benefit type, special payment, weekly rate, from and through dates and total amounts paid for each payment period. Interest payments, when applicable, should be reported on a separate line from the accrued benefit period(s) and include the special payment code, through date and total interest payment only. 1 American LegalNet, Inc. www.FormsWorkflow.com FILING INSTRUCTIONS FOR FORM 701 PART A This section must be completed in its entirety the first time the Form 701 is filed on a claim. On all subsequent filings, only items 1-3 and 17-21 are necessary. All other items do not need to be completed unless they have changed from the previous filing. Extreme care should be taken to ensure that all filings contain the same SSN and DOI that were first reported to the Bureau. #1. Social Security Number: 9 digit numeric. #2. Date of Injury: Must be complete date (MM/DD/YYYY). #3. Employee Name: Employee's last name, first name and middle initial. #4. Date of Birth: Must be complete date (MM/DD/YYYY) #5. Date of Death: If employee is deceased, enter complete date (MM/DD/YYYY). A Form 106 must also be filed. #6-9. Employee's Address: Complete address of employee, including number, street, city, state and zip code. #10. Employer Name: Enter complete business name of employer (DBA, etc.) #11. Federal ID Number: Enter 9 digit Federal ID number used by the employer listed in #10. #12. Injury Location Code: This item only needs to be completed if the employer has multiple locations. A three digit code was assigned by the bureau for each different location, and carriers were notified of the codes in 1991. Enter the location code corresponding to the address where the claimant was employed at the time of injury. #13-16. Employer Address: Complete address of employer, including number, street, city, state and zip code. #17. Carrier or Self-Insured Name: Enter complete name of insurance company or self-insured employer. A service agent name should not be reported in this field. #18. NAIC or Self-Insured Number: 5 digit NAIC number and 3 digit group code should be reported for insurance companies and 8 digit self-insured ID number should be reported for self-insureds. #19. Service Agent Name: Enter name of service agent handling claim, if applicable. #20. Service Agent ID Number: The 3 digit service agent ID number assigned by the bureau must be reported if a service agent name is present in #19. #21. Zip Code of Issuing Office: Zip code of insurance carrier, self-insured employer or service company filing the form. The zip code will be used in conjunction with the carrier or service agent ID to identify the mailing address of the appropriate office where correspondence should be sent. #22. Carrier or Self-Insured Claim Number: Submitter's claim or file number, if applicable. This number will appear on all system generated correspondence. 2 American LegalNet, Inc. www.FormsWorkflow.com #23. Date Carrier Received Notice of Injury: The date carrier received notice of injury. This information is required on the first filing of all voluntary payment cases to determine promptness of payment. If it is not present on the form, a system generated letter will be sent to the submitter. #24. Date First Payment Made: The date the first check was sent out on this claim. This date is required on the first filing of all voluntary payment cases to determine promptness of payment. If it is not present on the form, a system generated letter will be sent to the submitter. If the employer is continuing to pay wages while the compensability issue is being resolved or benefits are being coordinated under a wage continuation plan, the date first payment made should be the same as the from date in Part D. PART B The section must be completed in its entirety the first time the form is filed on a claim. On all subsequent filings, the items only need to be completed if they have changed. #25. Nature of Injury: Provide a brief description of the injury or disease. If desired, the codes from Table 212 (see attached) may be entered in addition to the description. #26. Part of Body: Provide a brief description of the part of body affected by the injury or disease. If desired, the codes from Table 211 (see attached) may be entered in addition to the description. #27. Average Weekly Wage: Include total weekly wages from place of injury, excluding fringes. This information is required. #28. Discontinued Fringes: Weekly fringe benefits from place of injury which are not continuing during the disability period. This information is required if the weekly compensation base rate is less than 2/3 of the state average weekly wage for the year of injury. If this situation occurs and there are no discontinued fringes, enter zero. #29. Second Employer AWW: Include total wages from second employer, if applicable. #30. Second Employer Discontinued Fringes: Include discontinued fringes from second employer, if applicable. #31. Tax Filing Status on Date of Injury: Employee's tax filing status at the time of injury using the Federal income tax eligibility criteria. The status does not change during the life of the claim. This information is required. #32. Last Day Worked: Last day preceding the current disability period in which the employee received full wages. This information is required. #33. Number of Days in Work Week: Number of days the employee is regularly scheduled to work per week. This information is required. If the employee works less than a 5 day week, we are unable to calculate the total amount paid. Therefore, if any of these claims are in open payment status at the end of the year, a Form 701 must be filed reporting the amount of compensation paid during the year. All payments made for dates of injury on and after May 11, 1999 must be calculated on a 7-day work week per Rule 408.31a. #34. Number of Dependents: Number of dependents, not including the employee. This information is required. 3 American LegalNet, Inc. www.FormsWorkflow.com PART C This section must be completed in its entirety each time the form is filed unless the reason for filing is "C" (terminating benefits). In that instance, only item 35 (reason for filing) is necessary. The information should always pertain to the latest payment period reported on the form, i.e., when filing is to report a rate change, the information in part C should correspond to the new rate. #35. Reason for Filing: A= B= C= D= E= F= G= H= I= The appropriate code must be entered on all filings: Used whenever benefits are commencing and continuing. Used whenever there is a change in the current rate and benefits are continuing. Used whenever benefits that were previously reported are now being terminated. Used whenever benefits that have never been previously reported are both commencing and terminating. Used whenever the rate is staying the same but reimbursements are now being received from either the Silicosis, Dust Disease and Logging Industry Compensation Fund; the Self-Insurers' Security Fund; or the Vocationally Handicapped Provisions of the Second Injury Fund. Used whenever a claim that had previously been in payment status is now reopening and benefits are continuing. Used whenever benefits are both commencing and terminating on a claim that had previously been in payment status. Used to report the amount of partial benefits that were paid on all claims which are in partial benefit status as of 12/31. A wage statement should also be attached. This code should also be used when reporting yearly payments on any claim still in payment status at the end of the year in which the employee worked less than a 5 day work week. Used whenever information was improperly reported on a previous Form 701. #36. Weekly Compensation Base Rate: The base rate which is owed prior to taking into account any adjustment(s) specified in item 37. #37. Weekly Adjustments to Base Rate: This item should always be completed when the base rate in item 36 does not match the "total weekly rate" in Part D. Record the appropriate code(s) and weekly dollar amount(s). If the code is equal to A-G (coordination of benefits), the appropriate section in Part E should also be completed on the back of the form. If the code is equal to "J" or "K", the order number must also be entered in the space provided below Part D. #38. Weekly Amount Being Indicate the appropriate code(s) and weekly dollar amount(s) being Reimbursed by a Fund: reimbursed by the Silicosis, Dust Disease and Logging Industry Compensation Fund; the Self-Insurers' Security Fund; or the Vocationally Handicapped Provisions of the Second Injury Fund. Do not record any Compensation Supplement Fund payments (adjustment code of "I") or Second Injury differential benefits (adjustment code of "L"). These amounts should be reported in #37. Also, do not report any reimbursements received as a result of the 70% or Dual Employment provisions. This information will be provided to us by the Second Injury Fund. 4 American LegalNet, Inc. www.FormsWorkflow.com PART D This section should be completed as follows: FILING REASON of "A" or "F" Complete the basis of payment, benefit type, special payment (if applicable), weekly rate and from date. FILING REASON of "B" Complete the entire first line (except for termination reason) in order to close out the old rate, as well as the first half of the second line in order to report the new rate and from date. If benefits covered more than one calendar year, the from date on the first line should always be January 1 of the current year. FILING REASON of "C" Complete the entire first line showing the total payments made for the current calendar year only. FILING REASON of "D" or "G" Complete the entire first line showing the total payments that were made. FILING REASON of "E" Complete the entire first line in order to close out the rate and payment period (if payments covered multiple calendar years, use January 1 of the current calendar year) for which the carrier is responsible, as well as the first half of the second line in order to give us the new from date for which reimbursement takes effect. FILING REASON of "H" Complete the entire first line (except for termination reason) in order to report the partial payments that were made during the previous calendar year (show the through date as close to 12/31 as possible) as well as the first half of the second line using a from date one day after the through date. A partial payment worksheet must also be attached to the form. BASIS OF PAYMENT Indicate the appropriate code from the back of the form. When a claim is being paid pursuant to any type of order, including a Voluntary Payment Form (MDL-1-115), include the order number in the space provided below Part D. BENEFIT TYPE Include the appropriate code from the back of the form. This information is always necessary unless a Special Payment type code is present. Please note that the old benefit type of Temporary Total has been replaced by General Disability. Also, the first filing reporting a specific loss benefit type ("C") should include a copy of the amputation chart signed by the physician or affidavit of vision loss, whichever applies. The number of loss weeks and effective date of loss should be completed below Part D. When benefits are changing from partial to total, or partial benefits are being terminated, a wage statement showing the calculation of partial payments must also be attached to the Form 701. When the benefit type is "D" (Permanent Total), there must be an adjustment code of "L" (SIF differential benefits) and an amount reported in #37. SPECIAL PAYMENT This code is only necessary when the payment period is pursuant to an award. When interest is being reported, the through date should reflect the date that the accrued benefits were paid. 5 American LegalNet, Inc. www.FormsWorkflow.com TOTAL WEEKLY RATE This should reflect the amount the employee actually receives per week and should equal the Base Rate in line 36 plus or minus any adjustments reported in line 37. The weekly rate can be left blank when the benefit type is "B" (partial wage loss). FROM DATE The effective date of the rate/benefit type for the payment period. Do not include the waiting week for the initial disability period unless benefits were paid for those dates. When terminating benefits that were paid during more than one calendar year, the from date should always reflect the current year only. This field may be left blank when special payment code is "B" (interest). THROUGH DATE The ending date (current calendar year only) of the rate/benefit type or the payment termination date, whichever applies. If a special payment code of "B" (interest) is being reported, the through date should reflect the date accrued benefits were paid. TOTAL AMOUNT PAID Indicate the total amount paid to the employee for the payment period. This field is required whenever a through date is present. If an overpayment was made but not recouped, the amount actually paid to the employee should be reflected. If partial benefits are being terminated, the total amount paid must be entered in Part D. It is not sufficient to simply attach a partial payment worksheet. TERMINATION REASON When the reason for filing is "C", "D" or "G" (all terminating benefits), the termination reason code is required. When the termination reason is "B" (recovered from disability), a medical report must be attached. Whenever partial benefits are being terminated, a partial payment worksheet must be attached to the form. If the termination reason is "E" (claimant deceased), a death certificate must be attached. ORDER # This number is required on all Form 701's that are filed pursuant to an award, including voluntary payment agreements (Form 115's). Enter the 9 digit order number which is located in the upper right hand corner of all orders mailed out by the Bureau. SPECIFIC LOSS If the benefit type code is "C" (specific loss), this information is required on the first filing. Enter the exact number of specific loss weeks as well as the effective date of the loss. An amputation chart (MDL-728) or vision affidavit, whichever is applicable, should also be attached. "OTHER" FILING CODES If any of the codes used on the form refer to "other", the exact reason must be listed here. #39. Authorized Signature: The signature of an individual authorized to file this form. #40. Person Handling Claim: Print the name of the individual who is handling the claim. This is the person we will contact with any questions. #41. Telephone Number: Enter the telephone number, including extension, of the individual listed in #40 who is handling the claim. #42. Date: Enter the date the form was prepared. 6 American LegalNet, Inc. www.FormsWorkflow.com NOTICE OF COMPENSATION PAYMENTS Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Filing# ________ Part A 1. Social Security Number 2. 6. Date of Injury 3. Employee Name (Last, First, MI) Employee Street Address 7. 4. 10. Employer Name 5. Date of Death 8. City Date of Birth (MM/DD/YYYY) State 9. ZIP Code 11. Federal I.D. Number 13. Employer Street Address 15. State 14. City 12. Injury Location Code 16. ZIP Code 17. Carrier or Self-Insured Name 18. NAIC or Self-Insured Number 19. Service Company/TPA Name (If applicable) 20. Service Company/TPA I.D. Number 21. ZIP Code of Issuing Office 22. Carrier or Self-Insured Claim Number 23. Date Carrier Received Notice of Injury 24. Date First Payment Made Part B 25. Nature of Injury 26. Part of Body 27. Average Weekly Wage 28. Discontinued Fringes 29. Second Employer A.W.W. 30. Second Employer Discontinued Fringes 31. Tax Filing Status on Date of Injury 32. Last Day Worked 33. Number of Days in Work Week 34. Number of Dependents Part C 35. Reason for Filing 36. Weekly Compensation Base Rate 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type Special Payment Total Weekly Rate From Through Total Amount Paid Year Paid Termination Reason If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) 41. Telephone Number 42. Date NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Filing Codes for Form BWC-701 31. A = B = C = D = Tax Filing Status Single Single/Head of Household Married/Filing Joint Married/Filing Separate 35. A = B = C = D = E = F = G = H = I = Reason for Filing Commencing Benefits Change in Weekly Rate Terminating Benefits Commencing and Terminating Benefits Reimbursement by a Fund Reopening Claim Reopening and Closing Claim Yearly Report of Partial Payments Error on Previous filing (attach copy) Part D - Basis of Payment A = Voluntary Payment B = Open Award C = Closed Award D = Stipulated Award E = Compromise F = Form 115 Voluntary Pay 37. A = B = C = D = E = F = G = H = I = J = K = L = M = N = O = P = Q = Weekly Adjustments to Base Rate Wage Continuation Offset (-) Social Security Coordination (-) Pension Offset (-) Unemployment Offset (-) Disability Insurance Offset (-) Self Insurance Offset (-) Other Benefit Coordination (-) Age 65 Reduction (-) Compensation Supplement (+) Advance Payment (-) 30% Appeal Adjustment (-) SIF Differential Benefits (+) Double Compensation (+) Third Party Offset (-) 2 Years Continuous Disability (+) Recoupment of Overpayment (-) Other Part D - Benefit Type A = General Disability B = Partial Wage Loss C = Specific Loss D = Permanent Total E = Death F = Other 38. Reimbursement by a Fund * A = Silicosis, Dust Disease and Logging Industry Compensation Fund B = Self-Insurers’ Security Fund C = Vocationally Handicapped Provisions/SIF D = Other * DO NOT report reimbursements received as a result of the 70% or Dual Employment provisions. This information will be provided to us by the Second Injury Fund. Part D - Special Payment A = Accrued Benefits B = Interest C = 30% Appeal Adjustment D = Other Part D - Termination Reason A = Returned to Work with No Wage Loss B = Recovered from Disability (Attach Medical) C = Award Reversed D = End of Specific Loss E = Claimant Deceased (Attach Death Certificate) F = Closing Out Weekly Due to Redemption G = Closing Out Weekly Due to Advance Payment H = Other PART E. — Coordination of Benefits Section 1-5 1. Pension 2. Wage Continuation 3. Disability Insurance 4. Self Insurance 5. Other X 1.25 X 1.25 X 1.25 X 1.25 X 1.25 A. Weekly Benefit Amount B. 80% After-tax Amount of (A) C. 100% After-tax Amount D. FICA Tax* E. State Income Tax* F. % Employer Contribution G. Income to Be Coordinated** * ** Does not apply in all cases. If applicable, include the value of FICA and state income tax using the rates provided in the back of the bureau's rate tables corresponding to the year of injury. Line G = (Line C + D + E) X Line F (This figure should appear in Section 37 with the appropriate adjustment code) Section 6 - Social Security A. Monthly Old-Age Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ B. Weekly Old-Age Benefits (Above Amount ÷ 4.33) . . . . . . . . . . . . . . . . . . . . . . $ C. Total Amount of Social Security Benefits to be Coordinated (50% of Line B) . . $ (Enter with Code “B” in Section 37) Section 7 - Unemployment Compensation A. Number of Weeks Awarded . . . . . . . . . . . . . . . . . . . . . . $ B. Beginning Date of Unemployment Compensation . . . . . $ Scheduled Expiration Date C. Total Weekly Unemployment Compensation Benefits . . $ (Enter with Code “D” in Section 37) BWC-701 (Rev. 10/96) BACK Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Print Please complete all date fields with the MM/DD/YYYY format. Reset Form REPORT OF ACCRUED BENEFITS SS# ______________________ DOI ______________ Order # ____________________ Basis Payment Code __________ Benefit Type Special Payment Adjusted Rate From Employee Name _____________________________ Through Year Paid _____________ Total Variable Rate Factors Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Deps ____ Base Amt $ _______ Adjustment Code ___ $ _______ Adjustment Code ___ $ _______ Basis of Payment A = Voluntary Payment B = Open Award C = Closed Award D = Stipulated Award E = Compromise F = Form 115 Voluntary Pay Benefit Type A = General Disability B = Partial Wage Loss C = Specific Loss D = Permanent Total E = Death F = Other Weekly Adjustments to Base Rate A = Wage Continuation Offset B = Social Security Coordination C = Pension Offset D = Unemployment Offset E = Disability Insurance Offset F = Self-Insurance Offset G = Other Benefit Coordination H = Age 65 Reduction I = Compensation Supplement J= K= L= M= N= O= P= Q= Special Payment A = Accrued Benefits B = Interest C = 30% Appeal Adjustment D = Other Advance Payment 30% Appeal Adjustment SIF Differential Benefits Double Compensation Third-Party Offset 2-Years Continuous Disability Recoupment of Overpayment Other American LegalNet, Inc. www.FormsWorkflow.com Nature of Injury Codes – Alpha Order When two codes are listed, this first represents nature of injury and the second is part of body Code Description Code Description 300 Abrasions 160 Crush 183 Abscess 170 Cut 281 Aluminosis - aluminum exposure 950 100 Amputation or enucleation (loss of an eye) Damage to prosthetic devices (includes eyeglasses, false teeth, etc.) 272 Anemia 540 Depression 282 Anthracosis - coal dust 540 Derangement, internal 152 Anthrax 185 Dermatitis, allergenic or contact 540 Anxiety 180 Dermatitis, unspecified 283 Asbestosis - asbestos fibers 190 Dislocation & dislocated disc 110 Asphyxia 110 Drowning 572 Asthma 151 Dysentery, amebiasis 274 Asthma, toxic (systemic poisoning) 500 Effects of changes in atmospheric pressure (equilibrium) 552 Benign and unspecified tumor 590 Bites, human and non-toxic animal 300 Blisters 272 Blood diseases (includes purpura) 183 200/840 Electric shock, electrocution 274 Emphysema 240 Environmental heat (does not include sunburn) Boils 260 Epicondylitis 572 Bronchitis 995 Epilepsy 274 Bronchitis, toxic (systemic poisoning) 184 Erythema, toxic 153 Brucellosis 530 Eye diseases 160 Bruise 210 Fracture 130 Burn (chemical) 220 Freezing (includes frostbite) 120 Burn or scald (heat) 260 Ganglion cyst 260 Bursitis 276 Gastro-enteritis 284 Byssinosis - cotton dust 276 Gastro-intestinal diseases 551 Cancer 273 Hay fever, toxic (systemic poisoning) 183 Carbuncles 230 Hearing loss or impairment Carpal tunnel 991 Heart attack 310 Cartilage, torn 991 Heart conditions 183 Cellulitis 240 Heatstroke 561 Central nervous system 320 Hemorrhoids (circulatory system) 561 Cerebral palsy 330 Hepatitis (serum & infective) 510 Cerebrovascular & other circulatory conditions 250/410 Hernia, rupture 159 Chicken pox 190/240 Herniated disc 276 Colitis 159 Herpes 520 Complications peculiar to medical care (toxic or nontoxic) 991 Hypertension 150 Infective or parasitic disease, unspecified 572 Influenza 274 Influenza, toxic (systemic poisoning) 294 Ionizing radiation - Isotopes 562/320 140/110 Concussion (brain, cerebral) 154 Conjunctivitis (non-toxic) 530 Conjunctivitis, chemical 160 Contusion American LegalNet, Inc. www.FormsWorkflow.com Nature of Injury Codes – Alpha Order When two codes are listed, this first represents nature of injury and the second is part of body Code Description Code Description 293 Ionizing radiation - X-Ray 290 Radiation effects, unspecified 530 Iritis 570 Respiratory System, conditions of, unspecified 260 Joints, inflammation or irritation 581 Rhinitis 170 Laceration 273 Rhinitis, toxic (systemic poisoning) 551 Leukemia 310 Rotator cuff tear 184 Lichen 530 Loss of vision 551 Malignant tumor 285 Siderosis - metallic dust 159 Measles 286 Silicosis - silica dust 540 Mental disorders 273 Sinusitis, toxic (systemic poisoning) 292 Microwave, radiation effects 189 Skin conditions, unspecified 561 Migraine 995 Miscarriage 400 Multiple injuries 310 Sprains 159 Mumps 310 Strains 260 Muscles, inflammation or irritation 110 Strangulation 562 Nerves and peripheral ganglia (includes Bell's Palsy) 560 Nervous system, conditions of, unspecified 540 300 200/840 170 273/850 Scratches Shock, electric Sliver Smoke inhalation 540/840 Stress 510 Stroke 110 Suffocation Neurosis 291 Sunburn, etc. (non-ionizing radiation) 900 No injury or illness 240 Sunstroke 999 Nonclassifiable 580 Symptoms & ill-defined conditions (e.g., fainting) 990 Occupational disease (not elsewhere classified) 260 Tendinitis 159 Other infective diseases 260 Tendons, inflammation or irritation 995 Other injury, not elsewhere classified 260 Tenosynovitis, stenosing 287 Other pneumoconiosis and related diseases 156 Tetanus 184 Other skin conditions 275 Toxic hepatitis 279 Other toxic effects on one system only 157 Tuberculosis 190 Pinched nerve (back only) 550 Tumor, neoplasm, unspecified 310 Pinched nerve (other than back) 571 Upper respiratory 280 Pneumoconiosis & related diseases, unspecified 510 Varicose veins 289 Pneumoconiosis with tuberculosis 295 Welder's flash (eyes only) 572 Pneumonia 310 Whiplash 274 Pneumonia, toxic (systemic poisoning) 274 Pneumonitis 280 Pneumothorax 270 Poisoning, systemic, unspecified 271 Poisoning, toxic material 183 Primary Infections of the skin 184 Pruritus 170 Puncture American LegalNet, Inc. www.FormsWorkflow.com Part of Body Codes Code Description Code Description 410 Abdomen (include internal organs) 530 Foot (not ankle or toe) 520 Ankle 315 Forearm 318 Arm, multiple 149 Forehead 319 Arm, not elsewhere classified 330 Hand (not wrist or fingers) 310 Arm(s), above wrist, unspecified 397 Hand & Finger(s) 801 Arteries 198 Head, multiple 420 Back (include back muscles) 100 Head, unspecified 311 Biceps 801 Heart 820 Bladder 410 Hernia, inguinal 801 Blood 440 Hips 800 Body system, unspecified 311 Humerus 830 Bones 820 Intestines 110 Brain 141 Jaw 430 Breastbone 830 Joints 440 Buttocks 820 Kidneys 200 Cervical 513 Knee 141 Cheek 519 Leg, not elsewhere classified 430 Chest (internal organs) 518 Leg, multiple 141 Chin 510 Leg(s) (above ankle), unspecified 801 Circulatory system 144 Lips 450 Clavicle 500 Lower extremities, unspecified 420 Coccyx 598 Lower extremities, multiple 110 Concussion 515 Lower leg 450 Deltoid 420 Lumbar 810 Digestive system 850 Lungs 120 Ear(s), unspecified 141 Mandible 121 Ear(s), external 330 Metacarpal 124 Ear(s), internal 530 Metatarsal 313 Elbow 144 Mouth (includes sense of taste, excludes teeth) 840 Epilepsy 700 Multiple parts (use when more than one major body part has been affected) 830 Muscles 830 Musculo-skeletal system 146 Nasal passages 200 Neck 840 Nervous system 820 Excretory system 130 Eye(s) 130 Eyelid 148 Face, multiple parts 140 Face, unspecified 149 Face, not elsewhere classified 511 Femur 515 Fibula 999 Nonclassifiable (insufficient information to identify affected part) 340 Finger(s) 146 Nose (includes sense of smell) 350 Fingertip(s) 313 Olecranon American LegalNet, Inc. www.FormsWorkflow.com Part of Body Codes Code Description 130 Optic nerves 880 Other body systems 513 Patella 430 Pectorals 440 Pelvic organs 440 Pelvis 315 Radius 850 Respiratory system 430 Ribs 420 Sacrum 150 Scalp 450 Scapula 450 Shoulder(s) 146 Sinus 160 Skull 420 Spinal cord 420 Spine 430 Sternum 147 Teeth 830 Tendons 511 Thigh 430 Thorax 144 Throat 515 Tibia 540 Toe(s) 550 Toetip(s) 144 Tongue 311 Triceps 400 Trunk, unspecified 498 Trunk, multiple 315 Ulna 300 Upper extremities, unspecified 311 Upper arm 398 Upper extremities, multiple 801 Veins 130 Vision 320 Wrist American LegalNet, Inc. www.FormsWorkflow.com List of Examples Filing Reason “A” Commencing benefits (no adjustments to base rate Example 1 Filing Reason “A” Commencing benefits (with adjustments to base rate) Example 2 Filing Reason “B” Change in weekly rate Example 3 Filing Reason “C” Terminating benefits Example 4 Filing Reason “D” Commencing & terminating benefits Example 5 Filing Reason “E” Reimbursement by a Fund Example 6 Filing Reason “F” Reopening claim Example 7 Filing Reason “G” Reopening & Closing claim Example 8 Filing Reason “H” Yearly report of partial payments Example 9 Basis of Payment “B” Open award Example 10 Basis of Payment “E” Compromise Example 11 Benefit Type “D” Permanent Total Example 12 American LegalNet, Inc. www.FormsWorkflow.com Back to List of Examples Example 1 Filing Reason "A" Commencing benefits (no adjustments to base rate) NOTICE OF COMPENSATION PAYMENTS 1 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. Date of Injury 111-22-3333 6. 3. Employee Name (Last, First, MI) 02/01/1997 4. DOE, John R. Employee Street Address 7. Date of Birth (MM/DD/YYYY) City 8. ZIP Code MI 10. Employer Name 48910 11. Federal I.D. Number Smith's Auto Repair 12. Injury Location Code 002 38-1111111 13. Employer Street Address 14. City 3310 Baker Street 15. State Lansing 16. ZIP Code MI 17. Carrier or Self-Insured Name 48915 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office Date of Death 9. State Lansing 123 Elm Street 5. 09/04/1950 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48912 23. Date Carrier Received Notice of Injury D12345-1 24. Date First Payment Made 02/03/1997 02/07/1997 Part B 25. Nature of Injury 26. Part of Body Sprain (310) Ankle (520) 27. Average Weekly Wage 28. Discontinued Fringes $450.00 $0.00 31. Tax Filing Status on Date of Injury 29. Second Employer A.W.W. 33. Number of Days in Work Week 32. Last Day Worked 30. Second Employer Discontinued Fringes 34. Number of Dependents 02/01/1997 C 3 6 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate A $299.54 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From $299.54 02/02/1997 Through Total Amount Paid Year Paid Termination Reason If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 02/12/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Example 2 Back to List of Examples Filing Reason "A" Commencing benefits (with adjustments to base rate) NOTICE OF COMPENSATION PAYMENTS 1 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. Date of Injury 111-22-3333 6. 3. Employee Name (Last, First, MI) 02/01/1997 4. DOE, John R. Employee Street Address 7. 8. Date of Death 9. State Lansing ZIP Code MI 10. Employer Name 48910 11. Federal I.D. Number Smith's Auto Repair 12. Injury Location Code 002 38-1111111 13. Employer Street Address 14. City 3310 Baker Street 15. State Lansing 16. ZIP Code MI 17. Carrier or Self-Insured Name 48915 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office 5. 09/04/1950 City 123 Elm Street Date of Birth (MM/DD/YYYY) 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48912 23. Date Carrier Received Notice of Injury D12345-1 24. Date First Payment Made 02/03/1997 02/07/1997 Part B 25. Nature of Injury 26. Part of Body Sprain (310) Ankle (520) 27. Average Weekly Wage 28. Discontinued Fringes $450.00 $0.00 31. Tax Filing Status on Date of Injury 29. Second Employer A.W.W. 33. Number of Days in Work Week 32. Last Day Worked 30. Second Employer Discontinued Fringes 34. Number of Dependents 02/01/1997 C 3 6 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate A $299.54 37. Weekly Adjustments to Base Rate A $374.43 $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A Special Payment Total Weekly Rate A From Through Total Amount Paid Year Paid Termination Reason 02/02/1997 If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 02/12/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Back to List of Examples Filing Codes for Form BWC-701 31. A = B = C = D = Tax Filing Status Single Single/Head of Household Married/Filing Joint Married/Filing Separate 36. A = B = C = D = E = F = G = H = I = Reason for Filing Commencing Benefits Change in Weekly Rate Terminating Benefits Commencing and Terminating Benefits Reimbursement by a Fund Reopening Claim Reopening and Closing Claim Yearly Report of Partial Payments Error on Previous filing (attach copy) Part D - Basis of Payment A = Voluntary Payment B = Open Award C = Closed Award D = Stipulated Award E = Compromise F = Form 115 Voluntary Pay 37. A = B = C = D = E = F = G = H = I = J = K = L = M = N = O = P = Q = Weekly Adjustments to Base Rate Wage Continuation Offset (-) Social Security Coordination (-) Pension Offset (-) Unemployment Offset (-) Disability Insurance Offset (-) Self Insurance Offset (-) Other Benefit Coordination (-) Age 65 Reduction (-) Compensation Supplement (-) Advance Payment (-) 30% Appeal Adjustment (-) SIF Differential Benefits (+) Double Compensation (+) Third Party Offset (-) 2 Years Continuous Disability (+) Recoupment of Overpayment (-) Other Part D - Benefit Type A = General Disability B = Partial Wage Loss C = Specific Loss D = Permanent Total E = Death F = Other 38. Reimbursement by a Fund * A = Silicosis, Dust Disease and Logging Industry Compensation Fund B = Self-Insurers’ Security Fund C = Vocationally Handicapped Provisions/SIF D = Other * DO NOT report reimbursements received as a result of the 70% of Dual Employment provisions. This information will be provided to us by the Second Injury Fund. Part D - Special Payment A = Accrued Benefits B = Interest C = 30% Appeal Adjustment D = Other Part D - Termination Reason A = Returned to Work with No Wage Loss B = Recovered from Disability (Attach Medical) C = Award Reversed D = End of Specific Loss E = Claimant Deceased (Attach Death Certificate) F = Closing Out Weekly Due to Redemption G = Closing Out Weekly Due to Advance Payment H = Other PART E. — Coordination of Benefits Section 1-5 1. Pension 2. Wage Continuation A. Weekly Benefit Amount 4. Self Insurance 5. Other X 1.25 X 1.25 X 1.25 $450.00 B. 80% After-tax Amount of (A) 3. Disability Insurance $299.54 X 1.25 X 1.25 C. 100% After-tax Amount $374.43 D. FICA Tax* E. State Income Tax* 100% F. % Employer Contribution $374.43 G. Income to Be Coordinated** * ** Does not apply in all cases. If applicable, include the value of FICA and state income tax using the rates provided in the back of the bureau's rate tables corresponding to the year of injury. Line G = (Line C + D + E) X Line F (This figure should appear in Section 37 with the appropriate adjustment code) Section 6 - Social Security A. Monthly Old-Age Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ B. Weekly Old-Age Benefits (Above Amount ÷ 4.33) . . . . . . . . . . . . . . . . . . . . . . $ C. Total Amount of Social Security Benefits to be Coordinated (50% of Line B) . . $ (Enter with Code “B” in Section 37) Section 7 - Unemployment Compensation A. Number of Weeks Awarded . . . . . . . . . . . . . . . . . . . . . . $ B. Beginning Date of Unemployment Compensation . . . . . $ Scheduled Expiration Date C. Total Weekly Unemployment Compensation Benefits . . $ (Enter with Code “D” in Section 37) BWC-701 (Rev. 10/96) BACK Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Back to List of Examples Example 3 Filing Reason "B" Change in weekly rate NOTICE OF COMPENSATION PAYMENTS 1 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. Date of Injury 111-22-3333 6. 3. Employee Name (Last, First, MI) 02/01/1997 4. DOE, John R. Employee Street Address 7. Date of Birth (MM/DD/YYYY) City 8. ZIP Code MI 10. Employer Name 48910 11. Federal I.D. Number Smith's Auto Repair 12. Injury Location Code 002 38-1111111 13. Employer Street Address 14. City 3310 Baker Street 15. State Lansing 16. ZIP Code MI 17. Carrier or Self-Insured Name 48915 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office Date of Death 9. State Lansing 123 Elm Street 5. 09/04/1950 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48912 23. Date Carrier Received Notice of Injury D12345-1 24. Date First Payment Made 02/03/1997 02/07/1997 Part B 25. Nature of Injury 26. Part of Body Sprain (310) Ankle (520) 27. Average Weekly Wage 28. Discontinued Fringes $450.00 $0.00 31. Tax Filing Status on Date of Injury 29. Second Employer A.W.W. 33. Number of Days in Work Week 32. Last Day Worked 30. Second Employer Discontinued Fringes 34. Number of Dependents 02/01/1997 C 3 6 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate A $299.54 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From $299.54 02/02/1997 Through Total Amount Paid Year Paid Termination Reason If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 02/12/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Example 3 Back to List of Examples Filing Reason "B" Change in weekly rate NOTICE OF COMPENSATION PAYMENTS 2 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. 111-22-3333 6. Date of Injury 3. Employee Name (Last, First, MI) 02/01/1997 4. Date of Birth (MM/DD/YYYY) 5. Date of Death 8. State 9. ZIP Code DOE, John R. Employee Street Address 7. City 10. Employer Name 11. Federal I.D. Number 13. Employer Street Address 15. State 14. City 17. Carrier or Self-Insured Name 12. Injury Location Code 16. ZIP Code 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 23. Date Carrier Received Notice of Injury 24. Date First Payment Made 48912 Part B 25. Nature of Injury 26. Part of Body 27. Average Weekly Wage 28. Discontinued Fringes 29. Second Employer A.W.W. 30. Second Employer Discontinued Fringes 33. Number of Days in Work Week 34. Number of Dependents $0.00 31. Tax Filing Status on Date of Injury 32. Last Day Worked 2 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate B $299.54 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From Through A $299.54 02/02/1997 03/12/1997 A $294.52 Total Amount Paid 03/13/1997 $1,647.47 Year Paid Termination Reason 1997 If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 03/23/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Example 4 Back to List of Examples Filing Reason "C" Terminating Benefits NOTICE OF COMPENSATION PAYMENTS 1 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. Date of Injury 111-22-3333 6. 3. Employee Name (Last, First, MI) 02/01/1997 4. DOE, John R. Employee Street Address 7. Date of Birth (MM/DD/YYYY) City 8. ZIP Code MI 10. Employer Name 48910 11. Federal I.D. Number Smith's Auto Repair 12. Injury Location Code 002 38-1111111 13. Employer Street Address 14. City 3310 Baker Street 15. State Lansing 16. ZIP Code MI 17. Carrier or Self-Insured Name 48915 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office Date of Death 9. State Lansing 123 Elm Street 5. 09/04/1950 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48912 23. Date Carrier Received Notice of Injury D12345-1 24. Date First Payment Made 02/07/1997 02/03/1997 Part B 25. Nature of Injury 26. Part of Body Sprain (310) Ankle (520) 27. Average Weekly Wage 28. Discontinued Fringes $450.00 $0.00 31. Tax Filing Status on Date of Injury 29. Second Employer A.W.W. 33. Number of Days in Work Week 32. Last Day Worked 30. Second Employer Discontinued Fringes 34. Number of Dependents 02/01/1997 C 3 6 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate A $299.54 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From $299.54 02/02/1997 Through Total Amount Paid Year Paid Termination Reason If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 02/12/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Back to List of Examples Example 4 Filing Reason "C" Terminating Benefits NOTICE OF COMPENSATION PAYMENTS 2 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. 111-22-3333 6. Date of Injury 3. Employee Name (Last, First, MI) 02/01/1997 4. Date of Birth (MM/DD/YYYY) 5. Date of Death 8. State 9. ZIP Code DOE, John R. Employee Street Address 7. City 10. Employer Name 11. Federal I.D. Number 13. Employer Street Address 15. State 14. City 17. Carrier or Self-Insured Name 12. Injury Location Code 16. ZIP Code 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 23. Date Carrier Received Notice of Injury 24. Date First Payment Made 48912 Part B 25. Nature of Injury 26. Part of Body 27. Average Weekly Wage 28. Discontinued Fringes 29. Second Employer A.W.W. 30. Second Employer Discontinued Fringes 31. Tax Filing Status on Date of Injury 32. Last Day Worked 33. Number of Days in Work Week 34. Number of Dependents Part C 35. Reason for Filing 36. Weekly Compensation Base Rate C 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From Through Total Amount Paid Year Paid Termination Reason $299.54 02/02/1997 04/06/1997 $2,695.86 1997 A If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 04/12/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Example 5 Back to List of Examples Filing Reason "D" Commencing & Terminating Benefits NOTICE OF COMPENSATION PAYMENTS 1 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. Date of Injury 111-22-3333 6. 3. Employee Name (Last, First, MI) 02/01/1997 4. Date of Birth (MM/DD/YYYY) 8. State DOE, John R. Employee Street Address 7. Lansing 9. ZIP Code MI 10. Employer Name 48910 11. Federal I.D. Number Smith's Auto Repair 12. Injury Location Code 002 38-1111111 13. Employer Street Address 14. City 3310 Baker Street 15. State Lansing 16. ZIP Code MI 17. Carrier or Self-Insured Name 48915 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office Date of Death 09/04/1950 City 123 Elm Street 5. 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48912 23. Date Carrier Received Notice of Injury D12345-1 24. Date First Payment Made 02/03/1997 02/07/1997 Part B 25. Nature of Injury 26. Part of Body Burn (310) Arm (520) 27. Average Weekly Wage 28. Discontinued Fringes $450.00 $0.00 31. Tax Filing Status on Date of Injury 29. Second Employer A.W.W. 33. Number of Days in Work Week 32. Last Day Worked 30. Second Employer Discontinued Fringes 34. Number of Dependents 02/01/1997 A 0 5 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate D $274.40 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From Through Total Amount Paid Year Paid Termination Reason $274.00 02/02/1997 03/12/1997 $1,536.64 1997 A If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 03/13/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Example 6 Back to List of Examples Filing Reason "E" Reimbursement by a Fund NOTICE OF COMPENSATION PAYMENTS 1 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. Date of Injury 111-22-3333 6. 3. Employee Name (Last, First, MI) 03/06/95 4. Date of Birth (MM/DD/YYYY) DOE, John R. Employee Street Address 7. City 512 Baker Street 8. Date of Death 9. State Detroit ZIP Code MI 10. Employer Name 48226 11. Federal I.D. Number Fred's Foundry 12. Injury Location Code 001 38-2222222 13. Employer Street Address 14. City 4480 W. Fort Street 15. State Detroit 16. ZIP Code MI 17. Carrier or Self-Insured Name 48288 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office 5. 05/20/38 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48288 23. Date Carrier Received Notice of Injury WC654321 24. Date First Payment Made 03/10/1995 03/21/1995 Part B 25. Nature of Injury 26. Part of Body Silicosis (286) Lungs (850) 27. Average Weekly Wage 28. Discontinued Fringes $610.00 $0.00 31. Tax Filing Status on Date of Injury 29. Second Employer A.W.W. 33. Number of Days in Work Week 32. Last Day Worked 30. Second Employer Discontinued Fringes 34. Number of Dependents 03/06/1995 C 2 5 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate A $383.02 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From $383.02 03/07/1995 Through Total Amount Paid Year Paid Termination Reason If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 03/21/1995 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Example 6 Back to List of Examples Filing Reason "E" Reimbursement by a Fund NOTICE OF COMPENSATION PAYMENTS 2 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. 111-22-3333 6. Date of Injury 3. Employee Name (Last, First, MI) 03/06/1995 4. Date of Birth (MM/DD/YYYY) 5. Date of Death 8. State 9. ZIP Code DOE, John R. Employee Street Address 7. City 10. Employer Name 11. Federal I.D. Number 13. Employer Street Address 15. State 14. City 17. Carrier or Self-Insured Name 12. Injury Location Code 16. ZIP Code 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48288 23. Date Carrier Received Notice of Injury WC654321 24. Date First Payment Made 03/10/1995 03/21/1995 Part B 25. Nature of Injury 26. Part of Body 27. Average Weekly Wage 28. Discontinued Fringes 29. Second Employer A.W.W. 30. Second Employer Discontinued Fringes 33. Number of Days in Work Week 34. Number of Dependents $0.00 31. Tax Filing Status on Date of Injury 32. Last Day Worked Part C 35. Reason for Filing 36. Weekly Compensation Base Rate A $383.02 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) A 383.02 $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From Through Total Amount Paid Year Paid A $383.02 01/01/1997 03/03/1997 $3,370.58 1997 A $383.02 Termination Reason 03/04/1997 If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) Bill Parker 41. Telephone Number (517) 999-9999 42. Date 04/01/1997 NOTICE TO EMPLOYEE: If any of the above information is incorrect, please contact the individual named in line 40. BWC-701 (Rev. 10/96) FRONT Formerly Form MDL-1-701 American LegalNet, Inc. www.FormsWorkflow.com Example 7 Back to List of Examples Filing Reason "F" Reopening Claim NOTICE OF COMPENSATION PAYMENTS 1 Filing# ________ Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation P O Box 30016, Lansing, MI 48909 Part A 1. Social Security Number 2. Date of Injury 111-22-3333 6. 3. Employee Name (Last, First, MI) 02/01/1997 4. DOE, John R. Employee Street Address 7. 8. Date of Death 9. State Lansing ZIP Code MI 10. Employer Name 48910 11. Federal I.D. Number Smith's Auto Repair 12. Injury Location Code 002 38-1111111 13. Employer Street Address 14. City 3310 Baker Street 15. State Lansing 16. ZIP Code MI 17. Carrier or Self-Insured Name 48915 18. NAIC or Self-Insured Number United States Ins. Co. 99999999 19. Service Company/TPA Name (If applicable) 21. ZIP Code of Issuing Office 5. 09/04/1950 City 123 Elm Street Date of Birth (MM/DD/YYYY) 20. Service Company/TPA I.D. Number 22. Carrier or Self-Insured Claim Number 48912 23. Date Carrier Received Notice of Injury D12345-2 24. Date First Payment Made 02/03/1997 02/07/1997 Part B 25. Nature of Injury 26. Part of Body Arm (520) Burn (310) 27. Average Weekly Wage 28. Discontinued Fringes $450.00 $0.00 31. Tax Filing Status on Date of Injury 29. Second Employer A.W.W. 33. Number of Days in Work Week 32. Last Day Worked 30. Second Employer Discontinued Fringes 34. Number of Dependents 03/06/1995 A 0 5 Part C 35. Reason for Filing 36. Weekly Compensation Base Rate D $274.40 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported in line 37) $ Part D Basis of Payment Benefit Type A A Special Payment Total Weekly Rate From Through Total Amount Paid Year Paid Termination Reason $274.40 02/02/1997 03/12/1997 $1,536.64 1997 A If basis of payment is other than “A” (Voluntary Payment) or line 37 is equal to “J” or “K”, enter Order # If benefit type is “C” (Specific Loss), enter number of weeks and effective date of loss If any filing codes on this form represent “Other”, please be specific 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. Authority: Completion: Penalty: Workers’ Disability Compensation Act, 408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 This is to certify that a copy of this form has been mailed or given to the employee 39. Authorized Signature 40. Person Handling Claim (Please Print) B