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Workers Comp 100 Form

Workers Comp 100 Form

Use a michigan workers compensation forms template to make your document workflow more streamlined.

The date of injury; (b) Death; (c) Specific losses. In case of death, an employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures. I. EMPLOYEE DATA 1. Social Security Number 2. Date of injury 3. Employee name (Last, First, MI) 4. Address (Number & Street) 8. Date of birth (MM/DD/YYYY) 9. Sex Male 12. Tax filing status: A. Single 5. City 6. State 7. ZIP Code 10. Number of dependents 11. Telephone...
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