Multiple Carrier Redemption Form
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Multiple Carrier Redemption Form. This is a Michigan form and can be use in Workers Comp.
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Tags: Multiple Carrier Redemption Form, WC-113A, Michigan Workers Comp,
MULTIPLE CARRIER REDEMPTION FORM
Michigan Department of Labor & Economic Growth
Workers’ Compensation Agency/Board of Magistrates
PO Box 30016, Lansing, MI 48909
Plaintiff
Social Security Number
CARRIER 1
CARRIER 2
Employer
Employer
Insurance Company
Insurance Company
Date(s) of Injury
Date(s) of Injury
CARRIER 3
CARRIER 4
Employer
Employer
Insurance Company
Insurance Company
Date(s) of Injury
Date(s) of Injury
CARRIER
1
CARRIER
2
CARRIER
3
CARRIER
4
TOTAL
1. Attorney Fees
2. Attorney Expenses
3. Direct Payments (Medical)
4. Direct Payments (Non-medical)
5. Plaintiff’s Redemption Fee
6. Balance to Plaintiff
7. Allocated to Medical (Not included in 3 above)
8. Total Payment
9. Cost of Annuity (If applicable)
Carrier # _______ to remit defendant’s statutory redemption fee of $100.00 directly to State of Michigan.
Carrier # _______ to complete the payment of weekly compensation of $ _____________ per week through ____________________.
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, 418.835; 418.836; 418.837
Completion:
Voluntary
Penalty:
None
WC-113A (8/05)
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