EMPLOYER'S BASIC REPORT OF INJURY Michigan Department of Labor & Economic Growth Worker's Compensation Agency P.O. Box 30016, Lansing, MI 48909
An employer shall report immediately to the bureau on form WC-100 all injuries, including diseases, which arise out of and in the course of employment, or on which a claim is made and result in any of the following: (a) Disability beyond seven (7) consecutive days, not including the date of injury; (b) Death; © Specific losses. In case of death, an employer shall also immediately file an additional report on WC-106.

I. EMPLOYEE DATA
1. Social Security Number	2. Date of Injury (MM/DD/YYYY)	3b. Employee Last Name		3a. First Name and Middle Initial
4. Street Address		5. City	6. State	7. Zip Code
8. Date of Birth (MM/DD/YYYY)	9. Sex Male   Female	10. Number of Dependents	11. Telephone Number	11a. Extn.
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/NACIS)
19. Employer street address		20. City	21. State	22. Zip Code
23. Insurance company name			24. Insurance company phone
III.ALLEGED INJURY DATA
25. Last day worked	26. Date employee returned to work		27. Did employee die? YesNo	28. If yes, date of death
29. Injury city	30. Injury state	31. Injury county	32. Did injury occur on employer's premises? YesNo    (if no, see item 53)
33. Case number from OSHA/MIOSHA Log
34. Time employee began work ampm		35. Time of event ampm		if can't be determined click here
36. What was the employee doing just before the incident occured? 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 ladded 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? YesNo	43. Was employee hospitalized overnight as an in-patient? YesNo
44. If treatment was given away from the work site, where was it given? (include name, address, city, state and zip code of facility)
IV.OCCUPATION AND WAGE DATA
45. Date hired	46. Gross weekly wage (highest 39 of 52)		47. Number weeks used	48. Value of discontinued fringes
49. Occupation (be specific)	50. Was employee a volunteer worker? YesNo		51. Was employee certified as vocationally handicapped? YesNo
52. Date Employer notified by employee	53. If temporary service agency, provide name/address of employer where injury occured.
V.PREPARER DATA	I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE
Making a false or fradulent 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		55. Preparer's signature	56. Telephone number	57. Date prepared
Sender Name	Sender Email