Supplemental Report Of Fatal Injury
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Supplemental Report Of Fatal Injury Form. This is a Michigan form and can be use in Workers Comp.
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Tags: Supplemental Report Of Fatal Injury, WC-106, Michigan Workers Comp,
SUPPLEMENTAL REPORT OF FATAL INJURY
Michigan Department of Licensing and Regulatory Affairs
Workers' Compensation Agency
PO Box 30016, Lansing, MI 48909
THIS REPORT IS TO BE FILED BY THE EMPLOYER IMMEDIATELY AFTER THE DEATH OF AN INJURED EMPLOYEE.
I. DECEASED EMPLOYEE
1. Social Security Number
2. Date of Injury
3. Date of Death
6. City
7. State
4. Name (Last, First, Middle Initial)
5. Street Address
II. EMPLOYER DATA
9. Employer Name
8. ZIP Code
10. Federal I.D. Number
11. Street Address
12. City
13. State
14. ZIP Code
15. Amount of Burial Expenses Paid (If Not Previously Reported)
$
III. DEPENDENTS OF EMPLOYEE
16.
Name
20. Employer’s Signature
18.
17.
Date of Birth
Relationship to Deceased
(Spouse, Child, or Other - Please Specify Other)
21. Title
LARA is an equal opportunity employer/program. Auxiliary aids, services and
other reasonable accommodations are available upon request to individuals
with disabilities.
WC-106 (10/11)
19.
Extent of Dependency
(Total/Partial)
22. Date
Authority:
Workers’ Disability Compensation Act, R408.31(3)
Completion: Mandatory
Penalty:
Workers’ Disability Compensation Act 418.631
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