Wc 104A Form PDF Details

The WC 104A form, officially titled "Application for Mediation or Hearing – Form A," is a vital document for employees in Michigan seeking to resolve disputes under the Workers' Disability Compensation Act. Managed by the Michigan Department of Labor and Economic Opportunity’s Workers’ Disability Compensation Agency, it serves as the initial step for workers who have encountered issues such as injury or disability during their employment and are seeking compensation or rehabilitation services. The form requires detailed information, including personal details of the employee, specifics of the employment and the injury or disablement, and the type of relief sought. An integral aspect of this application process is its exclusivity to employees; each application must be unique to the employer involved, and incomplete submissions are returned. The form also outlines the necessity for individuals to disclose whether the application involves contested claims for medical or wage loss benefits, any other employment at the time of injury, and any additional benefits received. Moreover, the necessity to list witnesses and healthcare providers underscores the importance of thorough and accurate documentation in supporting the claim. By certifying the application, the claimant verifies the truthfulness of all provided information and acknowledges the legal implications of false statements. This comprehensive process, while perhaps daunting, is essential for ensuring workers' rights are upheld and disputes are resolved efficiently.

QuestionAnswer
Form NameWc 104A Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmichigan 104a, michigan application mediation hearing form, application mediation hearing form, application mediation hearing

Form Preview Example

OCR 104A

APPLICATION FOR MEDIATION OR HEARING – FORM A

Michigan Department of Labor and Economic Opportunity

Workers’ Disability Compensation Agency

P.O. Box 30016, Lansing, MI 48909

Application Type

Initial

Amended

Penalty Only

Voc Rehab Only

THIS FORM TO BE USED BY EMPLOYEES ONLY.

A SEPARATE WC-104A MUST BE FILED FOR EACH EMPLOYER. INCOMPLETE APPLICATIONS SHALL BE RETURNED.

1. NAME OF EMPLOYEE (Last, First, MI)

2. SOCIAL SECURITY NUMBER

3. DATE OF BIRTH

4.

STREET NUMBER AND NAME

 

 

8. TAX FILING STATUS

 

 

 

 

 

 

A. Single

C. Married, Filing Joint

 

 

 

 

 

 

5.

CITY

6. STATE

7. ZIP CODE

B. Single, Head

D. Married, Filing

 

 

 

 

 

of Household

Separate

 

 

 

 

9. DATE OF DEATH (If Applicable)

 

 

 

 

 

 

 

 

10. NAME OF DEPENDENTS

 

 

11. RELATIONSHIP TO EMPLOYEE

12. BIRTH DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. NAME OF EMPLOYER

 

 

19. DATES OF EMPLOYMENT

 

 

 

FROM:

 

TO:

14. FEDERAL I.D. NUMBER (If Known)

 

 

20. EARNINGS

 

 

 

 

 

$

 

HOURLY/WEEKLY

15. STREET ADDRESS

 

 

21. CITY OF INJURY

 

 

 

 

 

 

 

 

16. CITY

17. STATE

18. ZIP CODE

22. COUNTY OF INJURY

 

 

 

 

 

 

 

23. DATE(S) OF INJURY

DURATION OF DISABLEMENT

 

INSURANCE CARRIER

 

FROM

TO

 

(DO NOT FILL IN)

 

 

 

 

 

 

24. DESCRIBE THE NATURE OF THE DISABILITY AND THE MANNER IN WHICH THE INJURY OR DISABLEMENT OCCURRED, AND SPECIFY THE RELIEF SOUGHT.

25. DID THE EMPLOYEE HAVE ANY OTHER EMPLOYMENT AT THE TIME OF THE INJURY? IF YES, LIST NAME AND ADDRESS OF THE EMPLOYER AND GROSS WEEKLY WAGE.

HAS A CLAIM BEEN FILED WITH THIS SECOND EMPLOYER?

26. HAS THE EMPLOYEE HAD ANY EMPLOYMENT SINCE THE DATE OF INJURY? IF YES, LIST THE NAME AND ADDRESS OF THE EMPLOYER.

27. DOES THIS APPLICATION INVOLVE A DISPUTED CLAIM FOR MEDICAL BENEFITS? IF YES, GIVE APPROXIMATE AMOUNT.

28. DOES THIS APPLICATION INVOLVE A DISPUTED CLAIM FOR WAGE LOSS BENEFITS? IF YES, HAS THE DISABILITY NOW ENDED?

29. HAS THE EMPLOYEE RETURNED TO WORK? IF YES, DATE OF RETURN

/

/

YES

NO

YES

NO

 

 

YES

NO

 

 

YES

NO

 

 

YES

NO

YES

NO

 

 

YES

NO

WC-104A (Rev. 12/20) FRONT

OCR 104A

30. IS THIS A CASE IN WHICH WAGE LOSS BENEFITS WERE PAID VOLUNTARILY AND HAVE BEEN TERMINATED WITHIN THE LAST 60 DAYS?

31. DOES THIS INVOLVE A CLAIM FOR VOCATIONAL REHABILITATION SERVICES?

32. IS A CLAIM BEING MADE AGAINST ONE OF THE FUNDS?

IF YES, PLEASE SPECIFY THE NAME OF THE FUND AND THE SPECIFIC PROVISION OF THE ACT.

YES

YES

YES

NO

NO

NO

33.

OTHER BENEFITS

 

 

 

(Please indicate which of the following benefits you are or have received based on employment with this employer during the periods of disability indicated on this application)

A.

OLD AGE SOCIAL SECURITY ____________________ WEEKLY/MONTHLY

E.

UNEMPLOYMENT BENEFITS __________________ WEEKLY/MONTHLY

B.

PENSION OR RETIREMENT PLAN ________________WEEKLY/MONTHLY

F.

DISABILITY INSURANCE POLICY _______________ WEEKLY/MONTHLY

C.

SICK AND ACCIDENT INSURANCE _______________ WEEKLY/MONTHLY

G.

SELF INSURANCE PLAN ______________________ WEEKLY/MONTHLY

D.

WAGE CONTINUATION PLAN ___________________ WEEKLY/MONTHLY

H.

PROFIT SHARING PLAN ______________________ WEEKLY/MONTHLY

34.

LIST THE NAMES AND ADDRESSES OF DOCTORS, HOSPITALS AND OTHER HEALTH CARE PROVIDERS WHO TREATED YOU FOR ANY DATE(S) OF INJURY LISTED IN #24.

 

 

 

 

 

 

 

 

NAME

ADDRESS (Street Number and Name)

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35.

LIST THE NAMES AND ADDRESSES OF ANY WITNESSES. (Do not list names of witnesses who are currently employed by the named employer)

 

 

 

 

 

 

 

 

 

 

NAME

ADDRESS (Street Number and Name)

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

36. I INTEND TO CALL WITNESSES WHO ARE CURRENTLY EMPLOYED BY THE NAMED EMPLOYER.

Yes

No

Making a false or fraudulent statement for the purpose of

AUTHORITY:

Workers’ Disability Compensation Act, 418.222; 418.847; R 408.34

obtaining or denying benefits can result in criminal or civil

COMPLETION:

Voluntary

prosecution, or both, and denial of benefits.

PENALTY:

None

 

 

 

CERTIFICATION AND SIGNATURE

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I ALSO CERTIFY THAT I HAVE, AS OF THIS DATE, MAILED TO MY EMPLOYER OR ITS INSURANCE CARRIER COPIES OF ANY MEDICAL RECORDS RELEVANT TO THIS CLAIM THAT ARE IN MY POSSESSION.

SIGNATURE OF APPLICANT

TELEPHONE NUMBER

()

DATE

ATTORNEY IDENTIFICATION

NAME OF ATTORNEY

NAME OF LAW FIRM

ATTORNEY I.D.

 

 

 

 

P.

 

 

 

 

 

 

 

ADDRESS (Street Number and Name)

CITY

 

STATE

 

ZIP CODE

 

 

 

 

 

SIGNATURE OF ATTORNEY

TELEPHONE NUMBER

DATE

 

 

(

)

 

 

 

 

 

 

 

 

 

WC-104A (Rev. 12/20) BACK

INSTRUCTIONS FOR COMPLETING FORM WC-104A

Michigan Department of Labor and Economic Opportunity

Workers’ Disability Compensation Agency

PO Box 30016, Lansing, MI 48909

Toll Free 1-888-396-5041

THIS FORM IS ONLY TO BE FILED BY (OR ON BEHALF OF) THE EMPLOYEE

The completed application must be mailed to the Workers’ Disability Compensation Agency at the above address. Please send only one copy.

If you require more space than is provided on the form, use a separate sheet of paper to provide the additional information.

APPLICATION TYPE

Initial

This box is to be checked if there are no previously filed form

 

104A’s pending.

Amended

This box is to be checked if there are previously filed form 104A’s

 

pending.

Penalty Only

This box is to be checked if the penalty provision under Section

 

418.801 is the only issue in dispute. Do not check this box if there

 

is also a question of entitlement to benefits.

VR Only

This box is to be checked if entitlement to vocational rehabilitation

 

services under Section 418.319 is the only issue in dispute. Do

 

not check this box if there is a question of entitlement to benefits.

NUMBERS 1-12 – EMPLOYEE INFORMATION

Complete all information regarding the injured employee. The complete social security number must be provided.

NUMBERS 13-18 – EMPLOYER INFORMATION

Complete the name and address of the employer. If the 9-digit Federal Employer Identification Number (FEIN) is known, it should be provided. A separate WC- 104A must be filed for each employer.

NUMBERS 19-23 – WAGE AND INJURY INFORMATION

Dates of employment should include at least the month and year. Provide wage information (circle either hourly or weekly) as well as the city and county where the injury occurred. List all alleged dates of injury or periods of disablement. Do not complete the insurance carrier information; this will be handled by the agency.

(REV. 12/20)

NUMBER 24 – NATURE OF DISABILITY

Describe the type of injury and how it occurred, and specify the relief sought. If this application involves a penalty issue, indicate the period of time for which a penalty is being sought.

NUMBERS 25-32

Answer yes or no and furnish additional information as applicable.

NUMBER 33 – OTHER BENEFITS

The Workers’ Disability Compensation Act requires you to disclose any benefits you have or are receiving from the employer during the periods of disability indicated in line 24 of this application. Also circle whether the amount listed is a weekly or monthly amount.

NUMBER 34 – DOCTORS, HOSPITALS, HEALTH CARE PROVIDERS

List the names and addresses of those who provided health care in relation to the injury or disablement.

NUMBERS 35 AND 36 – WITNESSES

Section 222 of the Workers’ Disability Compensation Act requires you to list on the application any witnesses to your work injury, however, do not include names of anyone who still works for the employer. Please also indicate whether you intend to call as witnesses any individuals who are currently employed by the employer.

CERTIFICATION AND SIGNATURE

By signing the application you are certifying that all information on the application is true to the best of your knowledge. Also, the Workers’ Disability Compensation Act requires that at the time of filing an Application for Mediation or Hearing-Form A, you must provide the employer or its workers’ compensation insurance carrier with any medical records relevant to this injury that are in your possession. When sending the medical records to the carrier or employer, they should be identified with your name, the employer’s name and address, date of injury and any other relevant information. Unsigned applications will be

returned.

ATTORNEY IDENTIFICATION

If you are represented by an attorney, all information in this section should be completed.

(REV. 12/20)

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How to complete ocr 104a part 1

2. When the last array of fields is complete, you're ready add the needed specifics in FROM, DO NOT FILL IN, DESCRIBE THE NATURE OF THE, DID THE EMPLOYEE HAVE ANY OTHER, IF YES LIST NAME AND ADDRESS OF, YES, HAS A CLAIM BEEN FILED WITH THIS, HAS THE EMPLOYEE HAD ANY, YES YES, NO NO, IF YES LIST THE NAME AND ADDRESS, DOES THIS APPLICATION INVOLVE A, IF YES GIVE APPROXIMATE AMOUNT, DOES THIS APPLICATION INVOLVE A, and IF YES HAS THE DISABILITY NOW ENDED in order to move forward further.

Part no. 2 for completing ocr 104a

3. This next step should also be quite uncomplicated, IS THIS A CASE IN WHICH WAGE LOSS, YES, DOES THIS INVOLVE A CLAIM FOR, IS A CLAIM BEING MADE AGAINST ONE, IF YES PLEASE SPECIFY THE NAME OF, YES, YES, OTHER BENEFITS, Please indicate which of the, OLD AGE SOCIAL SECURITY, PENSION OR RETIREMENT PLAN, SICK AND ACCIDENT INSURANCE, WAGE CONTINUATION PLAN, UNEMPLOYMENT BENEFITS, and DISABILITY INSURANCE POLICY - every one of these empty fields has to be filled out here.

YES, SICK AND ACCIDENT INSURANCE, and YES in ocr 104a

4. Completing LIST THE NAMES AND ADDRESSES OF, NAME, ADDRESS Street Number and Name, CITY, STATE, ZIP CODE, I INTEND TO CALL WITNESSES WHO, Yes, Making a false or fraudulent, Workers Disability Compensation, AUTHORITY COMPLETION PENALTY, SIGNATURE OF APPLICANT, TELEPHONE NUMBER, and DATE is vital in this fourth form section - ensure to don't rush and be mindful with every blank area!

Find out how to fill out ocr 104a portion 4

A lot of people frequently make mistakes while filling in TELEPHONE NUMBER in this section. You should definitely review everything you enter here.

5. This form needs to be wrapped up by going through this area. Here you'll find a full set of form fields that require specific information to allow your document submission to be accomplished: ATTORNEY IDENTIFICATION NAME OF, ADDRESS Street Number and Name, NAME OF LAW FIRM, ATTORNEY ID, CITY, STATE, ZIP CODE, SIGNATURE OF ATTORNEY, TELEPHONE NUMBER, DATE, and WCA Rev BACK.

Tips to fill in ocr 104a portion 5

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