Request For Compliance Hearing
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Request For Compliance Hearing Form. This is a Michigan form and can be use in Workers Comp.
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Tags: Request For Compliance Hearing, WC-40, Michigan Workers Comp,
REQUEST FOR COMPLIANCE HEARING
Michigan Department of Energy, Labor & Economic Growth
Workers' Compensation Agency
PO Box 30016, Lansing, MI 48909
Type of hearing requested
Rule 5
Rule 4(2)
Insurance Compliance
Other
Submitted on behalf of
Employee
Employer
Insurance Company
Other
Name of Employee (Last, First, MI)
Social Security Number
Plaintiff Attorney
Employee Street Address
Date of Birth
Plaintiff Attorney Tele. No.
Attorney ID Number
PCity
State
ZIP Code
Employee Telephone Number
Plaintiff Attorney Email Address
Name of Employer
Carrier or Self-Insured Name
Defendant Attorney
Employer Street Address
NAIC or Self-Insured Number
Defendant Attorney Tele. No.
Attorney ID Number
PCity
State
ZIP Code
Service Company/TPA Name (if applicable)
Defendant Attorney Email Address
A request for a hearing must contain sufficient information to warrant investigation or inquiry into an allegation of non-compliance. Please outline the facts
and law involved in this matter. Include names, dates, amounts, and any other pertinent information. Also, specify the relief sought.
Name of Requester
Telephone Number*
Street Address*
Email*
City*
State*
ZIP Code*
Signature
Date
* If not listed in upper portion of form
DELEG is an equal opportunity employer/program. Auxiliary aids, services and
other reasonable accommodations are available upon request to individuals with
disabilities.
Authority:
Completion:
Penalty:
MCL 418.205; 418.601, et seq.; R408.34; R408.35
Voluntary
None
WC-40 (9/09)
REQUEST FOR COMPLIANCE HEARING
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