Fill and Sign the Michigan Workers Form

Children      Birth date                                           NO YES Employment NO Date of Benefit Change: NO                                                                                                                                    Spouse                   Benefits calculated on a             Age Reduction Benefit Coordination Dependency Change (attach verification) Unemployment Compensation Other       YES Attach records confirming employment with evidence of weeks and hours worked, and earnings statement (Provide evidence on value of NO Attach information received verifying continuing disability and current activities       Weekly differential benefits paid on Fund's behalf:             weeks at $                               weeks at $             $                         weeks at $                               weeks at $                   $       $       FORM 112 APPLICATION FOR REIMBURSEMENT Michigan Department of Consumer & Industry Services Bureau of Workers' Disability Compensation Funds Administration 7201 W. Saginaw Hwy., Suite 110, Lansing, MI 48917 FUNDS ADMINISTRATION FUNDS ADMINISTRATION USE ONLY I Total & Permanent Disability Provision Section 521 (1) (2)2 70% Reimbursement Provision Section 8623 Two Years of Continuous Disability Provision Section 356 (I )4 Vocationally Handicapped Provision Ser-lion 925 REQUEST NUMBER 5 Dual Employment Provision Section 3726 Silicosis Dust Disease and Logging Industry Compensation Fund Section 531 CARRIER FILE NUMBER COMPLETE THIS SECTION FOR ALL FUNDSApplications for reimbursement should be submitted every six months unless otherwise indicated. EMPLOYEE NAME (Last, First, Middle) SOCIAL SECURITY 4 INJURY DATE BIRTH DATE EMPLOYEE ADDRESS (Street No. and Name) (City) (State) (zip) (Phone Number) NAME OF EMPLOYER EMPLOYER ADDRESS INSURANCE CO. OR SELF-INSURED EMPLOYER SERVICE COMPANY OR TPA (If Applicable) FEDERAL I.D. NUMBER CONTACT PERSON TELEPHONE NUMBER PAYMENT ADDRESS Tax filing status at time of injury Claimant's Average Weekly Wage Carrier/Employer Present Weekly Compensation Rate DEPENDENTS $ $ day week IS THERE A THIRD PARTY CLAIM?If YES, provide pertinent information on claim. HAS BASIC BENEFIT CHANGED DURING PERIOD? Attach 701 Reason for Change: HAS EMPLOYEE BEEN GAINFULLY EMPLOYED DURING PERIOD COVERED BY THIS REIMBURSEMENT? benefits if applicable) (1) COMPLETE this section when requesting reimbursement from the Second Injury Fund - TOTAL AND PERMANENT DISABILITY PROVISION: thru = $ I thru = $ I TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT (2) COMPLETE this section when requesting reimbursement from the Second Injury Fund - 70% REIMBURSEMENT PROVISION: (submit after all appeals are final) (a) Decision by Board of Magistrates ordering payment and order reversing/modifying decision:(b) Confirmation that ALL appeals are final (c) Copy of all 701s indicating payments (d) Written verification of dependents during appeal period NOTE: Request reimbursement for medical expenses paid under section 862(2) by completing BWDC form 271. 70% Benefits Paid on Appeal: thru I = $ thru I = $ Total 70% Benefits Paid: Minus: Dollar Value of final award, including interest (if applicable): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT $ BWC-112 (Revised 08/00) YES NO                   weeks at $                               weeks at $                   thru             weeks at $             thru             weeks at $             = $       $             $                         =                                           Phone:       $       Employer             Employer             Employer             $                   -                               weeks at $                               weeks at $             $       TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT             %(D) =$       thru             weeks at $             thru             weeks at $             thru             weeks at $             $       -       X       $                   (3) COMPLETE this section when requesting reimbursement from the Second Injury Fund -TWO YEARS OF CONTINUOUS DISABILITY PROVISION - Reimbursement due on a quarterly basisWeekly benefit rate paid on Second Injury Fund's behalf: thru I = $ thru I = $ TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT $ (4) COMPLETE this section when requesting reimbursement from the Second Injury Fund - VOCATIONALLY HANDICAPPED PROVISION - Vocational rehabilitation benefits under section 319 are reimbursable from the date of injury = $ I I Total weekly benefits paid on Fund's behalf: $ Medical expenses paid during period (attach copies of bills and reports): Vocational rehabilitation costs paid during period (attach copies of bills and reports): TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT $ (5) COMPLETE this section when requesting reimbursement from the Second Injury Fund -DUAL EMPLOYMENT PROVISION -Reimbursement due on a quarterly basis NOTE: (1) Include forms 100 & 701. Attach WAGE RECORDS for all employers. (2) Attach DOCUMENTATION OF DISABILITY, i.e., medical records. (3) Complete only Section 11 on continuous reimbursement cases, otherwise, complete both. INSTRUCTION FOR COMPLETION OF SECTION I- (1) 3 or more employers? Use separate sheet to provide information (employer, address, wages) required(2) Carry out apportionment percentages to one hundredths of a percentage (xx.xx% or .xxxx) (3) Average weekly wage with each employer is based upon number of weeks worked at that employer 1 . Name of Employer: Place of Injury WAGES NUMBER OFWEEKS USED AVERAGE $ $ (A) Name of Other Employer $ = $ Address: Total average weekly wagesFrom separate sheet (if applicable): $ (B) Has there been a return to work with any employer Date: If yes, complete section across: 0 Date: Date: II. Carrier/Employer Apportionment % of liability: Dual Employment Provision's % of liability: (A) - $ (B) = % (C) 100% (C) = % (D) If (D) is less than 20%, the DUAL EMPLOYMENT PROVISION has no liability pursuant to Section 372. Workers' Compensation Benefits paid during period: thru I = $ thru I = $ Total weekly benefits paid during this reimbursement period: (E) (E) x (6) COMPLETE this section when requesting reimbursement from the SILICOSIS & DUST DISEASE FUND or LOGGING INDUSTRY COMPENSATION FUND Weekly benefits paid during this period: I = $ I= $ I= $ Total benefits paid during periodMinus threshold on first reimbursement onlyApportionment percentage due (SDDF only): % TOTAL AMOUNT REQUESTED IN THIS REIMBURSEMENT: SIGNATURE OF AUTHORIZED REPRESENTATIVE TITLE DATE SUBMITTED Authority: Workers Disability Compensation Act R408.46 Completion: Voluntary Penalty: None The Department of Consumer & Industry Services will not discriminate against any individual orgroup because of race, sex, religion, age, national origin, color, marital status, handicap or politicalbeliefs.