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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. Number of dependents 10. Telephone number
11. Tax filing status: A. Single B. Single, Head of Household C. Married, Filing Joint D. Married, Filing Separate
II .EMPLOYER/CARRIER DATA
12. Employer name 13. Federal ID Number
14. Injury location code 15. Mailing location code 16. UI number 17. Type of business (SIC/NAICS)
18. Employer street address 19. City 20. State 21. ZIP code
22. Insurance company name (if employer not self-insured) 23. Insurance company telephone number (if known)
III .INJURY/MEDICAL DATA
24. Last day worked 25. Date employee returned to work (if applicable) 26. Did employee die? 27. If yes, date of death
Yes No
28. Injury city 29. Injury state 30. Injury county 31. Did injury occur on employer's premises?
Yes No (If no, see item 53)
32. Case number from OSHA/MIOSHA log 33. Time employee began work 34. Time of event If time cannot be determined,
a.m. p.m . a.m. p.m . check here
35. 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.
36. 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”
37. Describe the nature of injury or illness 38. Part of body directly affected by the injury or illness
39. 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.
40. Name of physician or other health care professional 41. Was employee treated in an emergency room? 42. Was employee hospitalized overnight as an in-patient?
Yes No Yes No
43. 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
44. Date hired 45. Total gross weekly wage (highest 39 of 52) 46. Number of weeks used 47. Value of discontinued fringes
48. Occupation (Be specific) 49. Was employee a volunteer worker? 50. Was employee certified as vocationally handicapped?
Yes No Yes No
51. Date employer notified by employee 52. 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.
53. Preparer's name (Please print or type) 54. Preparer's signature 55. Telephone number 56. Date prepared
Notice to employee: Questions or errors should be reported immediately to the individual listed above in space 54
WC-100 (Rev. 1220/ ) Front