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Workers' Compensation Fund Blue Arrows

Reporting Procedures

Use the Employer’s Report of Injury – Short Form When:

  • Employee reports an on-the-job injury, whether medical treatment is required or not, and

  • Employee misses up to 7 consecutive days from work, and

  • Circumstances of incident/injury are not questionable.

Use the Employer’s Report of Injury – Long Form / Form 100 When:

  • Employee reports an on-the-job injury and requires medical treatment, and

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

  • Circumstances of incident/injury are questionable.

  • Payroll information must be submitted.


Always Include:

  • Employer Incident Report, if applicable.

  • All medical reports/notes.

  • All medical bills

Do not hold the Employer’s Report of Injury form pending wages, medical reports/ notes, or medical bills. Send the Injury Report in immediately and submit additional information when available.

Notice of Hearing/Attorney Letter

  • Submit all hard copies of attorney letters and petitions directly to Connie See, Regional Claims Manager in Grand Rapids. Her contact information is: Fax: 616-825-5948; Phone: 800-752-7477 x 4122

  • Do not provide records to the employee or the attorney.

Acknowledgement

  • You will receive an email containing copies of all the forms you’ve submitted online for your records.

  • You will receive a phone call from a claims representative within 48 hours on all lost-time claims.

  • Contact the MML Fund/Meadowbrook Claim Service with questions.



 

 

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