Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P O Box 30016, Lansing, MI 48909 1. Social Security No. 2. Date of Injury 3. Employee Name (Last, First, MI) 5. City 6. State 7. ZIP Code 9. Federal ID No. 11. City 12. State 15. NAIC or Self-Insured No. 18. Service Co./TPA ID No. 21. County of Injury 13. ZIP Code 16. ZIP Code 19. ZIP Code 22. County Code (if known) NOTICE OF DISPUTE 4. Employee Address (Street No. and Name) 8. Employer Name 10. Employer Street Address 14. Carrier or Self-Insured Name 17. Service Company/TPA Name (if applicable) 20. Claim or File No. 23. Reason for Dispute A. B. C. D. E. F. Injury not work related Medical treatment not related to injury Further investigation required (please specify below) Additional information required from employee (please specify below) Vocational rehabilitation dispute only (please specify below) Other (please specify below) 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, R408.33 (1) Mandatory Workers' Disability Compensation Act, 418.631; 418.801; R408.33 This is to certify that a copy of this form has been mailed or given to the injured employee. 24. Preparer's Name (Please print) 25. Signature 26. Telephone No. 27. Date NOTICE TO EMPLOYEE By filing this form, your employer or its workers' compensation insurance company has indicated to the Workers' Compensation Agency that it has a q uestion or a dispute concerning the possible workers' compensation benefits to which you may be entitled. You may or may not agree with the position taken by the employer or insurance company. If you feel that you are not receiving the benefits to which you are entitled, you should discuss this with your employer or a representative of its insurance company. If you have already done that or you are not satisfied with the discussion, you may file a formal a pplication for mediation or hearing. You can obtain the appropriate forms or more infor mation by contacting the Workers' Compensation Agency at our toll-free number of 1-888-396-5041. Additional information may also be found on our website at www.michigan.gov/wca. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-107 (Rev. 2/13) American LegalNet, Inc. www.FormsWorkFlow.com WC-107 � Notice of Dispute Instructions A carrier shall notify the Workers' Compensation Agency on or before the fourteenth day after the employer has notice or knowledge of the alleged injury or death, in all cases where the right of the injured or dependent to compensation is disputed. Required fields: All applicable fields must be completed. Forms will be returned if fields 1-3, 8, and 14 are not completed. You will receive a letter if fields 4 and 23 are not completed. Do not use "Other" as reason for dispute unless absolutely necessary. Send a copy of the completed signed form to the employee. Mail the original signed form to: Workers' Compensation Agency PO Box 30016 Lansing, MI 48909 American LegalNet, Inc. www.FormsWorkFlow.com