Workers Settlement Statement
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Workers Settlement Statement Form. This is a Michigan form and can be use in Workers Comp.
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Tags: Workers Settlement Statement, WC-544, Michigan Workers Comp,
WORKER’S SETTLEMENT STATEMENT
Michigan Department of Labor & Economic Growth
Workers’ Compensation Agency
PO Box 30016, Lansing, MI 48909
Plaintiff
Defendant
v.
1a. Current Settlement Payment
$
1b. 70% Benefits Paid (if any)
$
1c. Total Redemption Settlement Amount
$
ATTORNEY EXPENSES UNDER R408.44(5)
2a.
$
2b.
$
2c.
$
2d.
$
2e. Total Expenses
$
ATTORNEY FEE CALCULATION UNDER R408.44(3)(4)(7)
3a.
Base for Fee Calculation
(Total Redemption Minus Total Expenses)
$
3b.
% of first $25,000
=
$
3c.
% above $25,000
=
$
=
$
3d.
% X
3e.
Total Attorney Fee
$
4.
Redemption Fee
$
100.00
DIRECT PAYMENTS
5a.
$
5b.
$
5c.
$
5d.
Total Direct Payments
$
6.
70% Benefits Paid
$
7.
Total Expenses, Attorney Fees, Redemption Fee, Direct Payments and 70% Benefits
$
8.
Net Amount to Plaintiff (1c minus 7)
$
Date
I certify that I have read and approved of this statement.
Plaintiff
Attorney for Plaintiff
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.
WC-544 (Rev. 7/05)
AUTHORITY R408.44(3)
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