(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Number Date of Injury The plaintiff and defendant agree that the plaintiff's Application for Mediation or Hearing is withdrawn.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. American LegalNet, Inc. www.USCourtForms.com