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 4. Name (Last, First, Middle Initial) 5. Street Address 6. City 7. State 8. ZIP Code II. EMPLOYER DATA 9. Employer Name 10. Federal I.D. Number 12. City 13. State 14. ZIP Code 11. Street Address 15. Amount of Burial Expenses Paid (If Not Previously Reported) $ III. DEPENDENTS OF EMPLOYEE Name 16. Date of Birth 17. (Spouse, Child, or Other - Please Specify Other) Relationship to Deceased 18. Extent of Dependency (Total/Partial) 19. 20. Employer's Signature 21. Title 22. Date 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) Authority: Workers' Disability Compensation Act, R408.31(3) Completion: Mandatory Penalty: Workers' Disability Compensation Act 418.631 American LegalNet, Inc. www.FormsWorkFlow.com