REQUEST FOR COMPLIANCE HEARING Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 Type of hearing requested Submitted on behalf of Name of Employee (Last, First, MI) Employee Street Address City State Rule 5 Employee Rule 4(2) Employer Insurance Compliance Insurance Company Other Other Plaintiff Attorney Plaintiff Attorney Tele. No. Plaintiff Attorney Email Address Attorney ID Number Social Security Number Date of Birth ZIP Code Employee Telephone Number P- Name of Employer Employer Street Address City State ZIP Code Carrier or Self-Insured Name NAIC or Self-Insured Number Service Company/TPA Name (if applicable) Defendant Attorney Defendant Attorney Tele. No. Attorney ID Number P- 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 Street Address* City* State* ZIP Code* Telephone Number* Email* Signature Date * If not listed in upper portion of form LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-40 (1/12) Authority: Completion: Penalty: MCL 418.205; 418.601, et seq.; R408.34; R408.35 Voluntary None REQUEST FOR COMPLIANCE HEARING American LegalNet, Inc. www.FormsWorkFlow.com