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Workers' Compensation Fund Blue Arrows

Claims Reporting Guide & Forms

 

Using the latest version of Acrobat Reader to be able to complete the forms below is recommended.

If you have trouble emailing these forms, please either fax or mail it to: 

MML WC Claims
3501 Lake Eastbrook, S.E., Suite 150
Grand Rapids, MI  49546-5975
Phone: 800-752-7477
Fax: (616) 942-0390

Guidance Materials

Claim Forms

Employer’s Report of Injury – Short Form

Complete Short Form Online or Print a Copy

  • On-the-job injury whether medical treatment is required or not, and

  • Employee’s time away from work does not exceed seven (7) days, and

  • Circumstances of incident/injury are not questionable.

Employer’s Basic Report of Injury – Long Form/Form 100

Complete Long Form Online or Print a Copy

  • On-the-job injury that requires medical treatment, and

  • Employee misses 8 or more consecutive days from work, or

  • Circumstances of incident/injury are questionable.

Supporting Forms

Payroll Worksheet
Complete Payroll Worksheet online or Print a Copy

Incident Report
Complete Incident Report online or Print a Copy

Order for Medical Treatment
Print Blank Copy

Mileage Log
Print Blank Copy

 

 

 



 

 

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