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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) .9 Sex 10. Number of dependents 11. Telephone number
Male Female
12. Tax filing status: A. Single 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 No
29. Injury city 30. Injury state 31. Injury county 32. Did injury occur on employer's premises?
Yes No
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
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. 0819/ ) Front