Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909 Plaintiff Name Defendant(s) Full Social Security Number Address Carrier(s) REDEMPTION ORDER Personal Service Day of Mailed 20 Magistrate (please print) 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 $ $ $ $ $ OTHER PAYMENTS PAYABLE TO / FOR ATTORNEY Fees $ Federal ID # MEDICAL PAYMENTS (include Federal ID#) Expenses $ $ $ $ $ $ 100.00 State of Michigan for statutory redemption fee PLAINTIFF Cost of annuity, if applicable Balance directly to plaintiff Do not write in this area. IT IS FURTHER ORDERED that defendant remit defendant's statutory redemption fee of $100.00 directly to the State of Michigan.2 IT IS FURTHER ORDERED that defendant shall also continue the payment of per week through . weekly compensation of $ 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, th e mailing date o f this orde r, it shall stand as th e final decis ion of the Wo rkers' 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 red emption fees. Se nd one copy of this order w ith your payment. Checks are to be made pa yable to the State of Michigan and m ailed to WCA Redemption Fees, PO Box 30646, Lansing, Michigan 48909. Do not write in this area. LARA 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. 4/12) American LegalNet, Inc. www.FormsWorkFlow.com