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Voluntary Payment Form. This is a Michigan form and can be use in Workers Comp.
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Tags: Voluntary Payment Form, WC-115, Michigan Workers Comp,
(Personal Service)
VOLUNTARY PAYMENT FORM
(Mailed)
_____ Day of __________ 20
Michigan Department of Labor & Economic Growth
Workers' Compensation Agency/Board of Magistrates
P.O. Box 30016, Lansing, MI 48909
Magistrate/Mediator (Please print)
Plaintiff
Defendant
Plaintiff’s Social Security Number
Date of Injury
The plaintiff and defendant agree that the plaintiff's Application for Mediation or Hearing is withdrawn. The defendant
agrees to pay benefits on a voluntary basis in accordance with the following:
$____________________
$____________________
Subtotal
$____________________
Plus supplemental benefit
$____________________
TOTAL
$____________________
Benefits to be paid for the period from
b.
Weekly benefit rate
Less benefits to be coordinated
a.
____________________ through _________________
Medical expenses to be paid?
Yes
No
Yes
No
If yes, to whom?
c.
Reimbursement to group carrier?
d.
Atty. fee to be charged
Percent ______%
Amount $_____________________
Atty. Fed. I.D.# _____________________________
e.
Amount of interest to be paid $____________________
f.
Additional agreements (attach additional sheets if necessary)
Neither the payment of compensation nor the accepting of same by the employee or his/her dependents shall be considered
as a determination of the rights of the parties under this Act.
All benefits become due and payable on the day of personal service or the mailing date.
Plaintiff
Defendant
Representative of Plaintiff
Representative of Defendant
Date
Magistrate/Mediator
Authority:
Workers’ Disability Compensation Act 418.222; 418.223; 418.847; R408.33(2)(b)
Completion: Voluntary
Penalty:
None
WC-115 (Rev. 05/05)
The Department of Labor & Economic Growth will not discriminate against
any individual or group because of race, sex, religion, age, national origin,
color, marital status, disability, or political beliefs. If you need assistance with
reading, writing, hearing, etc., under the Americans with Disabilities Act, you
may make your needs known to this agency.
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