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(Personal Service)
(Mailed)
VOLUNTARY PAYMENT FORM
Michigan Department of Labor & Economic Growth Workers' Compensation Agency/Board of Magistrates P.O. Box 30016, Lansing, MI 48909
_____ Day of __________ 20
Magistrate/Mediator (Please print)
Plaintiff Defendant
Plaintiff's Social Security Number
Date of Injury
The plaintiff and defendant agree that the plaintiff's Application for Mediation or Hearing is withdrawn. The defendant agrees to pay benefits on a voluntary basis in accordance with the following:
a. Weekly benefit rate Less benefits to be coordinated Subtotal Plus supplemental benefit TOTAL Benefits to be paid for the period from b. c. d. e. f. Medical expenses to be paid? If yes, to whom? Reimbursement to group carrier? Atty. fee to be charged Yes No Amount $_____________________ Percent ______% Yes $____________________ $____________________ $____________________ $____________________ $____________________ ____________________ through _________________ No
Atty. Fed. I.D.# _____________________________ Amount of interest to be paid $____________________ Additional agreements (attach additional sheets if necessary)
Neither the payment of compensation nor the accepting of same by the employee or his/her dependents shall be considered as a determination of the rights of the parties under this Act. All benefits become due and payable on the day of personal service or the mailing date.
Plaintiff
Defendant
Representative of Plaintiff
Representative of Defendant
Date
Magistrate/Mediator
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.
Authority: Workers' Disability Compensation Act 418.222; 418.223; 418.847; R408.33(2)(b) Completion: Voluntary Penalty: None
WC-115 (Rev. 05/05)