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MULTIPLE CARRIER REDEMPTION FORM
Michigan Department of Labor & Economic Growth Workers' Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909
Plaintiff Social Security Number
CARRIER 1
Employer Employer
CARRIER 2
Insurance Company
Insurance Company
Date(s) of Injury
Date(s) of Injury
CARRIER 3
Employer Employer
CARRIER 4
Insurance Company
Insurance Company
Date(s) of Injury
Date(s) of Injury
CARRIER 1 1. Attorney Fees 2. Attorney Expenses 3. Direct Payments (Medical) 4. Direct Payments (Non-medical) 5. Plaintiff's Redemption Fee 6. Balance to Plaintiff 7. Allocated to Medical (Not included in 3 above) 8. Total Payment 9. Cost of Annuity (If applicable)
CARRIER 2
CARRIER 3
CARRIER 4
TOTAL
Carrier # _______ to remit defendant's statutory redemption fee of $100.00 directly to State of Michigan. Carrier # _______ to complete the payment of weekly compensation of $ _____________ per week through ____________________.
The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
WC-113A (8/05)
Authority: Completion: Penalty:
Workers' Disability Compensation Act, 418.835; 418.836; 418.837 Voluntary None