NOTICE OF COMPENSATION PAYMENTS Michigan Department of Labor & Economic Growth Workers’ Compensation Agency P.O. Box 30016, Lansing, MI 48909 FILING # ________ PART A 1. Social Security Number 2. Date of Injury 3. Employee Name (Last, First, MI) 8. State 10. Employer Name 9. ZIP Code 12. Injury Location Code 15. State 7. City 5. Date of Death 11. Federal ID Number 6. Employee Street Address 4. Date of Birth 16. ZIP Code N/A 13. Employer Street Address 14. City 17. Carrier or Self-Insured Name 18. NAIC or Self-Insured Number 19. Service Company/TPA Name (if applicable) 20. Service Company/TPA ID 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. $ 31. Tax Filing Status on Date of Injury 30. Second Employer Discontinued Fringes $ 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 on 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. 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 SPACE 40. WC-701 (Rev. 9/05) FRONT American LegalNet, Inc. www.FormsWorkflow.com FILING CODES FOR FORM WC -701 31. TAX FILING STATUS 37. WEEKLY ADJUSTMENTS TO BASE RATE A = SINGLE A = WAGE CONTINUATION OFFSET (-) 38. REIMBURSEMENT BY A FUND* A = SILICOSIS, DUST DISEASE & LOGGING INDUSTRY COMPENSATION FUND B = SINGLE/HEAD OF HOUSEHOLD B = SOCIAL SECURITY COORDINATION (-) B = SELF-INSURERS’ SECURITY FUND C = MARRIED/FILING JOINT C = PENSION OFFSET (-) C = VOCATIONALLY HANDICAPPED PROVISIONS/SIF D = MARRIED/FILING SEPARATE D = UNEMPLOYMENT OFFSET (-) D = OTHER E = DISABILITY INSURANCE OFFSET (-) F = SELF INSURANCE OFFSET (-) G = OTHER BENEFIT COORDINATION (-) 35. REASON FOR FILING *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. H = AGE 65 REDUCTION (-) A = COMMENCING BENEFITS I = COMPENSATION SUPPLEMENT (+) B = CHANGE IN WEEKLY RATE J = ADVANCE PAYMENT (-) C = TERMINATING BENEFITS K = 30% APPEAL ADJUSTMENT (-) D = COMMENCING AND TERMINATING BENEFITS L = SIF DIFFERENTIAL BENEFITS (+) E = REIMBURSEMENT BY A FUND M = DOUBLE COMPENSATION (+) F = REOPENING CLAIM N = THIRD PARTY OFFSET (-) G = REOPENING AND CLOSING CLAIM O = 2 YEARS CONTINUOUS DISABILITY (+) H = YEARLY REPORT OF PARTIAL PAYMENTS P = RECOUPMENT OF OVERPAYMENT (-) I Q = OTHER = ERROR ON PREVIOUS FILING (ATTACH COPY) PART D – BASIS OF PAYMENT PART D – BENEFIT TYPE PART D – SPECIAL PAYMENT A = VOLUNTARY PAYMENT A = GENERAL DISABILITY A = ACCRUED BENEFITS PART D – TERMINATION REASON A = RETURNED TO WORK WITH NO WAGE LOSS B = OPEN AWARD B = PARTIAL WAGE LOSS B = INTEREST B = RECOVERED FROM DISABILITY (ATTACH MEDICAL) C = CLOSED AWARD C = SPECIFIC LOSS C = 30% APPEAL ADJUSTMENT C = AWARD REVERSED D = STIPULATED AWARD D = PERMANENT TOTAL D = OTHER D = END OF SPECIFIC LOSS E = COMPROMISE E = DEATH F = FORM 115 VOLUNTARY PAY F = OTHER 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 figures provided in the back of the agency’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 BENEFIT (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 C. TOTAL WEEKLY UNEMPLOYMENT COMPENSATION BENEFITS / $ 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. WC-701 (Rev. 9/05) BACK / SCHEDULED EXPIRATION DATE / / (ENTER WITH CODE “D” IN SECTION 37) Authority: Completion: Penalty: Workers’ Disability Compensation Act, R408.31(6a-d) Mandatory Workers’ Disability Compensation Act, 418.631; 418.801 American LegalNet, Inc. www.FormsWorkflow.com