Personal Service REDEMPTION ORDER Michigan Department of Energy, Labor & Economic Growth Workers’ Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909 Mailed Day of 20 Magistrate (please print) Plaintiff Name Full Social Security Number Defendant(s) Address Carrier(s) If more than one defendant/carrier, also complete and attach Multiple Carrier Redemption Form WC-113A The agreement to redeem the defendant’s entire1 workers’ compensation liability for injuries sustained by the plaintiff on has been considered by a Magistrate. IT IS ORDERED that this agreement to redeem the defendant’s entire1 liability for workers’ is APPROVED DENIED. disability compensation benefits by the payment of $ 1 Medical left open _____ (only if initialed by Magistrate) IT IS FURTHER ORDERED that the above sum be paid as follows: AMOUNT PAYABLE TO / FOR ATTORNEY Fees $ $ Federal ID # Expenses $ MEDICAL PAYMENTS (include Federal ID#) $ $ $ $ OTHER PAYMENTS $ $ $ 100.00 State of Michigan for statutory redemption fee PLAINTIFF $ Cost of annuity, if applicable $ Balance directly to plaintiff IT IS FURTHER ORDERED that defendant remit defendant’s statutory redemption fee of $100.00 directly to the State of Michigan.2 Do not write in this area. IT IS FURTHER ORDERED that defendant shall also continue the payment of weekly compensation of $ per week through . Social Security Administration Information The worker is currently age The net payment of $ and has a remaining life expectancy of is allocated at the rate of $ years. per month. Signed this _______ day of ____ _ _________, 20 _______ County of _________________. Magistrate If a request by any of the parties for review by the director, or notice of review on the director’s own motion, is not filed with the Agency within 15 days from 2 personal service, or if mailed, the mailing date of this order, it shall stand as the final decision of the Workers’ Compensation Agency. Payment of benefits pursuant to this order and redemption fees are due upon expiration of the appeal period. Denial of this agreement does not discharge the liability for redemption fees. Send one copy of this order with your payment. Checks are to be made payable to the State of Michigan and mailed to WCA Redemption Fees, PO Box 30646, Lansing, Michigan 48909. Do not write in this area. DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Authority: Workers’ Disability Compensation Act 418.835; 418.836; 418.837 Completion: Voluntary; Penalty: None WC-113 (Rev. 4/09) Prior editions obsolete American LegalNet, Inc. www.FormsWorkFlow.com