Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909 Plaintiff Social Security Number MULTIPLE CARRIER REDEMPTION FORM Employer Insurance Company Date(s) of Injury CARRIER 1 Employer Insurance Company Date(s) of Injury CARRIER 2 Employer Insurance Company Date(s) of Injury CARRIER 3 Employer Insurance Company Date(s) of Injury CARRIER 4 CARRIER 1 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 2 CARRIER 3 CARRIER 4 TOTAL 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 ____________________. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals w ith disabilities. Authority: Completion: Penalty: Workers' Disability Compensation Act, 418.835; 418.836; 418.837 Voluntary None WC-113A (4/12) American LegalNet, Inc. www.FormsWorkFlow.com