Fill and Sign the Long Term Care Insurance Policy Illustration Form

Print Please complete all date fields with the MM/DD/YYYY format. Reset Form Fill-In Instructions NOTICE OF DISPUTE Michigan Department of Consumer & Industry Services Bureau of Workers' & Unemployent Compensation P O Box 30016, Lansing, MI 48909 1. Social Security No. 2. Date of Injury 4. Employee Address (Street No. and Name) 3. Employee Name (Last, First, MI) 5. City 6. State 7. Zip Code 8. Employer Name 9. Federal ID No. 10. Employer Street Address 12. State 13. Zip Code 14. Carrier or Self-Insured Name 15. NAIC or Self-Insured No. 16. Zip Code 17. Service Company/TPA Name (if applicable) 18. Service Co./TPA ID No. 19. Zip Code 20. Claim or File No. 11. City 21. County of Injury 22. County Code (if known) 23. Reason For Dispute A. B. C. D. E. F. Injury not work related Medical treatment not related to injury Further investigation required (please specify below) Additional information required from employee (please specify below) Vocational rehabilitation dispute only (please specify below) Other (please specify below) Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits. Authority: Completion: Penalty: Workers' Disability Compensation Act, R408.33(1) Mandatory Workers' Disability Compensation Act, 418.631; 418.801; R408.33 This is to certify that a copy of this form has been mailed or given to the injured employee. 24. Preparer Name (Please print) 25. Signature 26. Telephone No. 27. Date NOTICE TO EMPLOYEE By filing this form, your employer or its workers' compensation insurance company has indicated to the Bureau of Workers' Disability Compensation that it has a question or a dispute concerning the possible workers' compensation benefits to which you may be entitled. You may or may not agree with the position taken by the employer or insurance company. If you feel that you are not receiving the benefits to which you are entitled, you should discuss this with your employer or a representative of its insurance company. If you have already done that or you are not satisfied with the discussion, you may request an informal conference or file a formal application for mediation or hearing. You can obtain the appropriate forms or more information by contacting the Bureau of Workers' Disability Compensation at one of the offices listed below. DETROIT State of Michigan Plaza Building 1200 Sixth Street, 12th Floor (313) 256-2770 FLINT Bristol West Center G-1388 West Bristol Road (810) 760-2618 ESCANABA State Office Building 305 Ludington (906) 786-2081 GRAND RAPIDS 2942 Fuller Street N.E. (616) 447-2670 BWC-107 (Rev. 11/00) KALAMAZOO 940 N. 10th Street (616) 544-4440 LANSING AREA 2501 Woodlake Circle, Okemos (517) 241-9393 MOUNT CLEMENS 10th Floor, Old County Building 10 N. Main (810) 463-6577 PONTIAC NBD Building 28 N. Saginaw, Suite 1310 (810) 334-2497 SAGINAW State Office Building 411-K East Genesee (989) 758-1768 TDD in Lansing (517) 322-5987 Go back to Form # BWC-107 When Required: A carrier shall notify the bureau on or before the fourteenth day after the employer has notice or knowledge of the alleged injury or death, in all cases where the right of the injured or dependent to compensation is disputed. Required Fields: All applicable fields must be completed. Instructions: Form Name: Page 1 Notice of Dispute U Forms will be returned if fields 1-3, 8, and 14 are not completed. U You will receive a letter if fields 4 and 23 are not completed. U Do not use “Other” as reason for dispute unless absolutely necessary. Completing the Form: U Select the hand tool from the Acrobat toolbar menu. You can use the hand tool to move the page around so that you can view all areas. U Position the hand pointer inside a form field and click. The I-beam pointer allows you to type text. U To complete the "red boxes," using your mouse, position the cursor over the applicable box until the pointing finger icon appears and click. U Press Tab to accept the field change and go to the next field, or Press Shift + Tab to accept the field change and go to the previous field. U Use your mouse to select an area of the form that is not inside a form field before printing your form. U To print, be sure to use the printer button on the Acrobat toolbar menu to print the form instead of your web browser's print function. You may need to select the “Print as image” option in the print dialog box to print the completed form. U If you wish to print the form only, select "Print Current Page" or "Pages From: 1 To: 1" NOTE: Please complete all date fields with the MM/DD/YYYY format. If you have any comments on this fill-inform, please send them to bwdcinfo@cis.state.mi.us. Please include the keyword “Fill-In Form 107" with your comments. How to Submit This Form: U Print the completed form U Sign and make 2 copies ˜ Give a copy of the report to the employee ˜ Keep a copy for your records ˜ Mail the original signed Form 107 to: Bureau of Workers’ Disability Compensation P O Box 30016 Lansing MI 48909