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Blank Michigan Wc 100 PDF Form

The Michigan WC-100 form is an essential document used by employers to report work-related injuries or illnesses to the state’s Workers’ Disability Compensation Agency. This form must be completed and submitted when an employee experiences a disability lasting more than seven consecutive days, dies, or suffers specific losses due to their job. For timely reporting, fill out the form accurately and click the button below to get started.

Article Guide

The Michigan WC-100 form serves as a crucial document for employers reporting work-related injuries or illnesses to the state's Workers’ Disability Compensation Agency. This form must be completed promptly when an injury results in significant outcomes such as disability lasting more than seven consecutive days, death, or specific losses. It captures essential employee data, including personal identification details, injury specifics, and employer information. Additionally, it gathers medical data related to the injury, the circumstances surrounding the event, and relevant occupational and wage details. Employers must also include preparer information to certify the accuracy of the report. Adhering to the reporting requirements outlined in the Michigan Occupational Safety and Health Act and related regulations is imperative. Failure to comply can lead to penalties. The WC-100 form not only aids in documenting workplace incidents but also contributes to a broader understanding of workplace safety and injury prevention efforts within Michigan.

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OCR 100

EMPLOYER'S BASIC REPORT OF INJURY

Michigan Department of Labor and Economic Opportunity

Workers’ Disability Compensation Agency

PO Box 30016, Lansing, MI 48909

An employer shall report immediately to the agency on Form WC-100 all injuries, including diseases, which arise out of and in the course of the employment, or on which a claim is made and result in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including 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)

5. City

6. State

7. ZIP Code

8. Date of birth (MM/DD/YYYY)

12. Tax filing status:

A. Single

9. Sex

10. Number of dependents

11. Telephone number

Male

Female

B. Single, Head of Household

C. Married, Filing Joint

D. Married, Filing Separate

II. EMPLOYER/CARRIER DATA

13. Employer name

14. Federal ID Number

15. Injury location code

16. Mailing location code

17. UI number

18. Type of business (SIC/NAICS)

19. Employer street address

20. City

21. State

22. ZIP code

23. Insurance company name (if employer not self-insured)

24. Insurance company telephone number (if known)

III. INJURY/MEDICAL DATA

25.

Last day worked

26. Date employee returned to work (if applicable)

27. Did employee die?

28. If yes, date of death

Yes

29.

Injury city

30. Injury state

31. Injury county

32. Did injury occur on employer's premises?

Yes

No (If no, see item 53)

33. Case number from OSHA/MIOSHA log

34. Time employee began work

35. Time of event

If time cannot be determined,

a.m.

p.m.

a.m.

p.m.

check here

36.What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.

37.How did the injury occur? Examples: “When ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during replacement”

38. Describe the nature of injury or illness

39. Part of body directly affected by the injury or illness

40. What object or substance directly harmed the employee? Examples: concrete floor, chlorine, radial arm saw. If this question does not apply to the incident, leave it blank.


41. Name of physician or other health care professional	42. Was employee treated in an emergency room?		43. Was employee hospitalized overnight as an in-patient?
	Yes	No	Yes	No

44. If treatment was given away from the worksite, where was it given? (Include name, address, city, state and ZIP code of facility)

IV. OCCUPATION AND WAGE DATA

45. Date hired

46. Total gross weekly wage (highest 39 of 52)

47. Number of weeks used

48. Value of discontinued fringes


49. Occupation (Be specific)	50. Was employee a volunteer worker?			51. Was employee certified as vocationally handicapped?
		Yes	No		Yes	No
		Yes	No		Yes	No

52. Date employer notified by employee		53. If temporary service agency, provide name/address of employer where injury occurred.

V. PREPARER DATA I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE

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.

54. Preparer's name (Please print or type)

55. Preparer's signature

56. Telephone number

57. Date prepared

Notice to employee: Questions or errors should be reported immediately to the individual listed above in space 54

WC-100 (Rev. 8/19) Front

If you are using this form as a replacement for the Form 301 to document the specifics of an injury or illness for purposes of compliance with the work-related injury and illness logging requirements, follow the instructions in Section A only.

If you are using this form to report a workers’ compensation injury, follow the instructions in Section A and B.

Section A

This form can be used in lieu of the MIOSHA Form 301, Injury and Illness Incident Report. It is one of the first f orms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses (Form 300) and the accompanying Summary (Form 300A), these forms help the employer and MIOSHA develop a picture of the extent and severity of work-related incidents.

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out questions 1-9, 27-28, 33-45 and 54-57.

According to Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974, Part 11, Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, you must keep this

form on file for 5 years following the year to which it pertains. DO NOT mail this form to the Workers’ Disability Compensation Agency unless it meets the conditions listed below in Section

Section B

You must complete all questions on this form if the injury or disease results in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific loss. The original form must be mailed to the Workers’ Disability Compensation Agency, P.O. Box 30016, Lansing, MI 48909.

Authority:	Workers' Disability Compensation Act, 408.31(1)(3)
Completion:	Mandatory
Penalty:	Workers' Disability Compensation Act, 418.631

LEO is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

WC-100 (Rev. 8/19) Back

➤ PDF File

Form Specifications

Fact Name	Description
Form Purpose	The WC-100 form is used by employers in Michigan to report work-related injuries or diseases.
Reporting Requirement	Employers must report injuries immediately if they result in disability beyond seven consecutive days, death, or specific losses.
Governing Law	This form is governed by the Workers' Disability Compensation Act, specifically sections 408.31(1)(3) and 418.631.
Filing Deadline	Employers must complete and submit the form within seven calendar days of learning about a recordable injury or illness.
Employee Data	The form requires detailed employee information, including name, Social Security number, and date of birth.
Employer Information	Employers must provide their name, Federal ID number, and business type, among other details.
Injury Details	Specific questions about the injury, including its nature and how it occurred, must be answered in detail.
Emergency Treatment	The form inquires whether the employee received emergency treatment or was hospitalized overnight.
Preparer Certification	The individual completing the form must certify that a copy has been provided to the employee and sign it.
Record Keeping	Employers are required to keep the completed form on file for five years following the year of the incident.

Michigan Wc 100: Usage Guidelines

Filling out the Michigan WC-100 form is an essential step in reporting workplace injuries. After completing the form, ensure that it is submitted to the appropriate agency promptly, especially if the injury meets specific criteria. This will help facilitate the necessary processes for any claims that may arise.

Obtain the Michigan WC-100 form from the Michigan Department of Labor and Economic Opportunity website or other authorized sources.
Begin with Section I: Employee Data. Fill in the employee's Social Security Number, date of injury, full name, address, city, state, ZIP code, date of birth, sex, number of dependents, and telephone number.
Indicate the employee's tax filing status by selecting one of the options: Single, Single Head of Household, Married Filing Joint, or Married Filing Separate.
Move to Section II: Employer/Carrier Data. Enter the employer's name, Federal ID Number, injury location code, mailing location code, UI number, type of business, and the employer's street address, city, state, and ZIP code.
If applicable, provide the name and telephone number of the insurance company.
Proceed to Section III: Injury/Medical Data. Fill in the last day worked, date employee returned to work (if applicable), and whether the employee died. If yes, provide the date of death.
Complete the injury location details, including city, state, and county. Indicate if the injury occurred on the employer's premises.
Provide the OSHA/MIOSHA case number, time employee began work, and time of the event. If the time cannot be determined, check the appropriate box.
Describe the employee's activity just before the incident, how the injury occurred, the nature of the injury or illness, and the part of the body affected.
Specify what object or substance directly harmed the employee. Include the name of the physician or healthcare professional involved.
Indicate if the employee was treated in an emergency room or hospitalized overnight, and provide details of the treatment facility if applicable.
In Section IV: Occupation and Wage Data, fill in the date hired, total gross weekly wage, number of weeks used, value of discontinued fringes, and the specific occupation.
Answer whether the employee was a volunteer worker or certified as vocationally handicapped.
Document the date the employer was notified by the employee and provide the name and address of the employer if a temporary service agency was involved.
In Section V: Preparer Data, print or type the preparer's name, sign the form, provide a telephone number, and date it.
Ensure a copy of the report is given to the employee and keep the form on file for five years following the year to which it pertains.
Mail the original form to the Workers’ Disability Compensation Agency at the specified address if it meets the reporting conditions.

Your Questions, Answered

What is the Michigan WC-100 form?

The Michigan WC-100 form, also known as the Employer's Basic Report of Injury, is a document that employers must complete and submit to the Workers’ Disability Compensation Agency. It is used to report all work-related injuries, including diseases, that occur during employment. This form is essential for documenting incidents that lead to disability, death, or specific losses.

When should the WC-100 form be submitted?

The WC-100 form must be submitted immediately after an injury occurs if it results in a disability that extends beyond seven consecutive days, if there is a death, or if there are specific losses. The employer is responsible for reporting these incidents promptly to ensure compliance with Michigan law.

What information is required on the WC-100 form?

The form requires detailed information about the employee, the employer, and the specifics of the injury. This includes the employee's name, social security number, date of injury, details about the injury, and the employer's information. Additionally, it asks for specifics about the nature of the injury, the part of the body affected, and any medical treatment received.

What happens if the employee dies as a result of the injury?

If an employee dies due to a work-related injury, the employer must complete the WC-100 form and also file an additional report using the WC-106 form. This ensures that all necessary information is reported to the Workers’ Disability Compensation Agency for further processing.

Is the WC-100 form used for all types of workplace injuries?

Yes, the WC-100 form is used for all types of workplace injuries, including those that result in diseases. It is crucial for documenting any incident that leads to a claim for workers’ compensation benefits, ensuring that the employer meets their legal obligations.

How long must employers keep the WC-100 form on file?

Employers are required to keep the WC-100 form on file for five years following the year in which the injury occurred. This retention is important for compliance with the Michigan Occupational Safety and Health Act and helps in tracking the history of workplace injuries.

What should an employer do if they have questions about completing the form?

If an employer has questions or encounters errors while filling out the WC-100 form, they should report these issues immediately to the individual listed in the preparer section of the form. Prompt communication can help resolve any discrepancies and ensure accurate reporting.

Can the WC-100 form be used for purposes other than reporting injuries?

Yes, the WC-100 form can also be used in lieu of the MIOSHA Form 301 to document work-related injuries for compliance with logging requirements. However, when using it for this purpose, employers should follow specific instructions outlined in the form.

What are the penalties for failing to file the WC-100 form correctly?

Failing to file the WC-100 form correctly or submitting false information can result in criminal or civil prosecution, as well as denial of benefits. It is crucial for employers to complete the form accurately to avoid these serious consequences.

How can an employer ensure they are filling out the WC-100 form correctly?

To ensure correct completion of the WC-100 form, employers should carefully read the instructions provided on the form itself. They should also gather all necessary information before starting the form and consider consulting with a legal professional or human resources expert if they have any uncertainties.

Common mistakes

Incomplete Employee Information: Failing to provide all necessary details about the employee, such as the social security number or date of birth, can lead to delays in processing the report.
Incorrect Dates: Entering the wrong date of injury or last day worked can create confusion and complicate the claims process.
Missing Employer Information: Omitting critical employer details, like the employer's name or federal ID number, may result in the report being rejected.
Inaccurate Injury Description: Providing vague or unclear descriptions of how the injury occurred can hinder the investigation and resolution of the claim.
Neglecting Medical Data: Failing to include information about the medical treatment received, such as the name of the treating physician or emergency room visits, can affect the validity of the claim.
Not Reporting Deaths Promptly: If an employee dies due to a work-related incident, not filing the additional report (WC-106) immediately can lead to legal complications.
Incorrect Wage Reporting: Misreporting the employee's total gross weekly wage can impact the compensation calculations and result in disputes.
Failure to Sign and Date: Not signing or dating the form can invalidate the submission, as it is essential to certify the accuracy of the information provided.

Documents used along the form

The Michigan WC-100 form is essential for employers to report workplace injuries and illnesses. Several other forms complement this report, each serving a specific purpose in the workers' compensation process. Below are some of the commonly used documents alongside the WC-100.

WC-106: Report of Death - This form is required if an employee dies as a result of a workplace injury. It provides details about the incident and must be filed immediately after the death is reported.
MIOSHA Form 301: Injury and Illness Incident Report - This document is used to record specifics of work-related injuries or illnesses. It helps in compliance with logging requirements and must be completed within seven days of the incident.
Form 300: Log of Work-Related Injuries and Illnesses - Employers use this form to maintain a log of all recordable injuries and illnesses. It provides a comprehensive overview of workplace incidents and is updated annually.
Form 300A: Summary of Work-Related Injuries and Illnesses - This summary form is posted in the workplace and provides annual statistics on work-related injuries and illnesses. It must be completed and displayed by February 1 each year.
WC-100A: Employee's Claim for Benefits - This form is filled out by the injured employee to formally claim benefits under the workers' compensation system. It includes details about the injury and the impact on the employee's ability to work.

Each of these forms plays a crucial role in ensuring that workplace injuries are documented and addressed properly. Employers should familiarize themselves with these documents to facilitate compliance with Michigan's workers' compensation laws.

Similar forms

The Michigan WC-100 form is an important document for reporting workplace injuries and illnesses. However, it shares similarities with several other forms used in various contexts. Here’s a look at ten documents that are similar to the WC-100 form, highlighting how they align in purpose or function.

MIOSHA Form 301: This form is used to report work-related injuries and illnesses. Like the WC-100, it captures essential details about the incident, ensuring compliance with safety regulations.
OSHA Form 300: This log records all work-related injuries and illnesses. It complements the WC-100 by providing a broader overview of workplace safety and incident frequency.
OSHA Form 300A: The summary of the OSHA 300 log, this form provides an annual overview of workplace injuries. It serves a similar purpose to the WC-100 by helping employers track and analyze incidents.
WC-106: This form is specifically for reporting fatalities. Similar to the WC-100, it must be filed immediately when a death occurs, emphasizing the urgency in such cases.
Workers’ Compensation Claim Form: Used by employees to file a claim for benefits after a workplace injury. Like the WC-100, it requires detailed information about the incident and the injured party.
Employee Injury Report: Often used internally by companies, this document collects information about an employee’s injury. It serves a similar purpose to the WC-100 in documenting incidents.
Incident Report Form: This form is used to document any workplace incident, whether or not it results in injury. Like the WC-100, it aims to provide a clear record of events.
Health and Safety Incident Log: This log records all health and safety incidents within a workplace. Similar to the WC-100, it helps track trends and improve workplace safety.
Return-to-Work Form: This document is used to confirm an employee’s ability to return to work after an injury. It works in conjunction with the WC-100 to manage the employee's recovery process.
Claim for Compensation Form: Used to claim compensation for work-related injuries, this form aligns with the WC-100 by ensuring that all necessary information is provided for processing claims.

Each of these forms plays a vital role in maintaining workplace safety and ensuring that employees receive the necessary support after an injury. Understanding their similarities can help employers navigate the complexities of workplace injury reporting more effectively.

Dos and Don'ts

When filling out the Michigan WC-100 form, it is crucial to ensure accuracy and completeness. Here are seven important dos and don'ts to keep in mind:

Do provide accurate employee data, including the Social Security number and date of injury.
Do clearly describe how the injury occurred, including specific details about the activity and tools involved.
Do include the name and contact information of the healthcare professional who treated the employee.
Do ensure that all required fields are completed before submitting the form.
Don't leave any sections blank unless instructed to do so; incomplete forms can lead to delays.
Don't provide vague descriptions of the injury or incident; specificity is key for accurate reporting.
Don't forget to keep a copy of the completed form for your records, as it must be retained for five years.

By following these guidelines, you can help ensure that the reporting process goes smoothly and that all necessary information is communicated effectively.

Misconceptions

The Michigan WC-100 form is a crucial document for reporting workplace injuries. However, several misconceptions can lead to confusion about its purpose and requirements. Below are five common misconceptions along with clarifications.

Misconception 1: The WC-100 form is only for severe injuries.

This is not true. The form must be completed for any injury that results in a disability lasting more than seven consecutive days, death, or specific losses, regardless of the injury's severity.

Misconception 2: Employers can delay filing the WC-100 form.

In fact, employers are required to report injuries immediately. Delays can lead to complications in claims processing and potential penalties.

Misconception 3: The WC-100 form is optional if the employee does not seek medical treatment.

This is incorrect. Even if the employee does not seek medical treatment, the form must still be filed if the injury meets the reporting criteria.

Misconception 4: The WC-100 form replaces other required documentation.

The WC-100 does not replace other forms like the MIOSHA Form 301. It serves a specific purpose in the workers' compensation process and must be used alongside other required forms.

Misconception 5: Only the employer can fill out the WC-100 form.

While the employer is responsible for submitting the form, it can be completed by a designated preparer. This ensures that all necessary information is accurately reported.

Understanding these misconceptions can help ensure compliance with reporting requirements and facilitate the claims process for injured workers.

Key takeaways

Filling out the Michigan WC-100 form is an essential step for employers when reporting workplace injuries. Here are some key takeaways to keep in mind:

Immediate Reporting: Employers must report all work-related injuries, including diseases, immediately using the WC-100 form if the injury results in disability beyond seven consecutive days, death, or specific losses.
Accurate Employee Information: Ensure that all employee data, such as name, Social Security number, and date of injury, is filled out accurately. This information is crucial for processing the claim.
Injury Details Matter: Provide a detailed description of how the injury occurred, including the activity the employee was engaged in and any tools or equipment involved. Specific examples can clarify the circumstances of the incident.
Timeliness is Key: The form must be completed and submitted within seven calendar days of learning about the injury. This helps maintain compliance with reporting requirements.
Keep Records: Retain a copy of the WC-100 form for at least five years following the year of the incident. This is important for both legal compliance and potential future reference.

By following these guidelines, employers can ensure they are meeting their obligations while providing necessary support to injured employees.