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Michigan Department of Licensing and Regulatory Affairs Workers Compen Michigan Department of Licensing and Regulatory Affairs Workers Compen

Michigan Department of Licensing and Regulatory Affairs Workers Compen - PDF document

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Michigan Department of Licensing and Regulatory Affairs Workers Compen - PPT Presentation

Plaintiff Name Full Social Security Number Address Defendants Carriers If more than one defendantcarrier also complete and attach Multiple Carrier Redemptio ID: 898643

redemption ordered carrier payment ordered redemption payment carrier defendant fees compensation michigan workers

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1 Michigan Department of Licensing and Reg
Michigan Department of Licensing and Regulatory Affairs Workers’ Compensation Agency/Board of Magistrates PO Box 30016, Lansing, MI 48909 Plaintiff Name Full Social Security Number Address Defendant(s) Carrier(s) If more than one defendant/carrier, also complete and attach Multiple Carrier Redemption Form WC-113A The agreement to redeem the defendant’s entire workers’ compensation liability for injuries sustained by the plaintiff on has been considered by a Magistrate. IT IS ORDERED that this agreement to redeem the defendant’s entire liability for workers’ disability compensation benefits by the payment of $ is APPROVED DENIED. Medical left open _____ (only if initialed by Magistrate) IT IS FURTHER ORDERED that the above sum be paid as follows: PAYABLE TO / FOR Fees $ Federal ID # Expenses $ MEDICAL PAYMENTS (include Federal ID#) OTHER PAYMENTS $ State of Michigan for statutory redemption fee Cost of annuity, if applicable Personal Service Mailed Day of Magistrate (please print) Balance directly to plaintiff IT IS FURTHER ORDERED that defendant remit defendant’s statutory redemption fee of $100.00 directly to the State of Michigan.IT IS FURTHER ORDERED that defendant shall also continue the payment of weekly compensation of $ per week through Do not write in this area. Social Security Administration Information The worker is currently age and has a remaining life expectancy of years. The net payment of $ is allocated at the rate of $ per month. Signed this _______ day of ____ _ _________ , 20 _______ County of _________________. Magistrate If a request by any of the parties for review by the director, or notice of review on the director’s own motion, is not filed with the Agency within 15 days from personal service, or if mailed, the mailing date of this order, it shall stand as the final decision of the Workers’ Compensation Agency. Payment of benefits pursuant to this order and redemption fees are due upon expiration of the appeal period. Denial of this agreement does not discharge the liability for redemption fees. Send one copy of this order with your payment. Checks are to be made payable to the State of Michigan and mailed to WCA Redemption Fees, PO Box 30646, Lansing, Michigan 48909. Do not write in this area. LARA is an equal opportunity employer/pr. Auxiliary aids, services and other available upon request to individuals with disabilities. Authority: Workers’ Disability Compensation Act 418.835; 418.836; 418.837 Completion: Voluntary; Penalty: None WC-113 (Rev. 4/12) �0�L�F�K�L�J�D�Q��'�H�S�D�U�W�P�H�Q�W��R�I��/�D�E�R�U��D�Q�G��(�F�R�Q�R�P�L�F��2�S�S�R�U�W�X�Q�L�W�\��:�R�U�N�H�U�V�¶��'�L�V�D�E�L�O�L�W�\��&�R�P�S�H�Q�V�D�W�L�R�Q��$�J�H�Q�F�\��%�R�D�U�G��R�I��0�D�J�L�V�W�U�D�W�H�V��3�2��%�R�[���������/�D�Q�V�L�Q�J���0�,������� �3�O�D�L�Q�W�L�I�I��1�D�P�H�������������������������������������������� �)�X�O�O��6�R�F�L�D�O��6�H�F�X�U�L�W�\��1�X�P�E�H�U� �$�G�G�U�H�V�V� �'�H�I�H�Q�G�D�Q�W� �V�\f� � �&�D�U�U�L�H�U� �V�\f� If more than one defendant/carrier, also complete and attach Multiple Carrier Redemption Form WC-113A �7�K�H��D�J�U�H�H�P�H�Q�W��W�R��U�H�G�H�H�P��W�K�H��G�H�I�H�Q�G�D�Q�W�¶�V��H�Q�W�L�U�H ��Z�R�U�N�H�U�V�¶��F�R�P�S�H�Q�V�D�W�L�R�Q��O�L�D�E�L�O�L�W�\��I�R�U��L�Q�M�X�U�L�H�V��V�X�V�W�D�L�Q�H�G��E�\��W�K�H��S�O�D�L�Q�W�L�I�I��R�Q�� ����������������� ��K�D�V��E�H�H�Q��F�R�Q�V�L�G�H�U�H�G��E�\��D��0�D�J�L�V�W�U�D�W�H��IT IS ORDERED��W�K�D�W��W�K�L�V��D�J�U�H�H�P�H�Q�W��W�R��U�H�G�H�H�P��W�K�H��G�H�I�H�Q�G�D�Q�W�¶�V��H�Q�W�L�U�H ��O�L�D�E�L�O�L�W�\��I�R�U��Z�R�U�N�H�U�V�¶��G�L�V�D�E�L�O�L�W�\��F�R�P�S�H�Q�V�D�W�L�R�Q��E�H�Q�H�I�L�W�V��E�\��W�K�H��S�D�\�P�H�Q�W��R�I������� ��L�V�� APPROVED DENIED. �0�H�G�L�F�D�O��O�H�I�W��R�S�H�Q��B�B�B�B�B�� �R�Q�O�\��L�I��L�Q�L�W�L�D�O�H�G��E�\��0�D�J�L�V�W�U�D�W�H�\f� IT IS FURTHER ORDERED �W�K�D�W��W�K�H��D�E�R�Y�H��V�X�P��E�H��S�D�L�G��D�V��I�R�O�O�R�Z�V�� ����������������������������������������������3�$�����(���2����)�2�5� �)�H�H�V��� �� �)�H�G�H�U�D�O��,�'��� �(�[�S�H�Q�V�H�V��� �0�(�'�,�&�$�/��3�$��0�(�1�7�6�� �L�Q�F�O�X�G�H��)�H�G�H�U�D�O��,�'��\f� � � � � �2�7�+�(�5��3�$���(���6� � � ������������� �6�W�D�W�H��R�I��0�L�F�K�L�J�D�Q��I�R�U��V�W�D�W�X�W�R�U�\��U�H�G�H�P�S�W�L�R�Q��I�H�H� �&�R�V�W��R�I��D�Q�Q�X�L�W�\���L�I��D�S�S�O�L�F�D�E�O�H� ���3�H�U�V�R�Q�D�O��6�H�U�Y�L�F�H���������� ���0�D�L�O�H�G� � � �'�D�\��R�I� �������������������� �0�D�J�L�V�W�U�D�W�H�� �S�O�H�D�V�H��S�U�L�Q�W�\f� �%�D�O�D�Q�F�H��G�L�U�H�F�W�O�\��W�R��S�O�D�L�Q�W�L�I�I� IT IS FURTHER ORDERED��W�K�D�W��G�H�I�H�Q�G�D�Q�W��U�H�P�L�W��G�H�I�H�Q�G�D�Q�W�¶�V��V�W�D�W�X�W�R�U�\� �U�H�G�H�P�S�W�L�R�Q��I�H�H��R�I����������G�L�U�H�F�W�O�\��W�R��W�K�H��6�W�D�W�H��R�I��0�L�F�K�L�J�D�Q� IT IS FURTHER ORDERED �W�K�D�W��G�H�I�H�Q�G�D�Q�W��V�K�D�O�O��D�O�V�R��F�R�Q�W�L�Q�X�H��W�K�H��S�D�\�P�H�Q�W��R�I� �Z�H�H�N�O�\��F�R�P�S�H�Q�V�D�W�L�R�Q��R�I���� ��S�H�U��Z�H�H�N��W�K�U�R�X�J�K�� �'�R��Q�R�W��Z�U�L�W�H��L�Q��W�K�L�V��D�U�H�D�� Social Security Administration Information The worker is currently age��� and has a remaining life expectancy of ��� years. The net payment of $ ���������������������� is allocated at the rate of $ ��� per month. � �6�L�J�Q�H�G��W�K�L�V��B�B�B�B�B�B�B��G�D�\��R�I� �B�B�B�B����B����B�B�B�B�B�B�B�B�B ������B�B�B�B�B�B�B���&�R�X�Q�W�\��R�I��B�B�B�B�B�B�B�B�B�B�B�B�B�B�B�B�B���0�D�J�L�V�W�U�D�W�H��� ��Q�R�W�L�F�H��R�I��U�H�Y�L�H�Z��R�Q��W�K�H��G�L�U�H�F�W�R�U�¶�V��R�Z�Q��P�R�W�L�R�Q���L�V��Q�R�W��I�L�O�H�G��Z�L�W�K��W�K�H��$�J�H�Q�F�\��Z�L�W�K�L�Q�����G�D�\�V��I�U�R�P��S�H�U�V�R�Q�D�O��V�H�U�Y�L�F�H���R�U��L�I �P�D�L�O�H�G���W�K�H��P�D�L�O�L�Q�J��G�D�W�H��R�I��W�K�L�V��R�U�G�H�U���L�W��V�K�D�O�O��V�W�D�Q�G��D�V��W�K�H��I�L�Q�D�O��G�H�F�L�V�L�R�Q��R�I��W�K�H��:�R�U�N�H�U�V�¶��'�L�V�D�E�L�O�L�W�\��&�R�P�S�H�Q�V�D�W�L�R�Q��$�J�H�Q�F�\�� Payment of benefits pursuant to this order and redemption fees are due upon expiration of the appeal period���'�H�Q�L�D�O��R�I��W�K�L�V��D�J�U�H�H�P�H�Q�W��G�R�H�V��Q�R�W��G�L�V�F�K�D�U�J�H��W�K�H���O�L�D�E�L�O�L�W�\��I�R�U��U�H�G�H�P�S�W�L�R�Q��I�H�H�V���6�H�Q�G��R�Q�H��F�R�S�\��R�I� �W�K�L�V��R�U�G�H�U��Z�L�W�K� �\�R�X�U��S�D�\�P�H�Q�W���&�K�H�F�N�V��D�U�H��W�R��E�H��P�D�G�H��S�D�\�D�E�O�H��W�R��W�K�H��6�W�D�W�H��R�I��0�L�F�K�L�J�D�Q��D�Q�G��P�D�L�O�H�G��W�R��:�&�$��5�H�G�H�P�S�W�L�R�Q��)�H�H�V���3�2��%�R�[���������/�D�Q�V�L�Q�J���0�L�F�K�L�J�D�Q�������� �'�R��Q�R�W��Z�U�L�W�H��L�Q��W�K�L�V��D�U�H�D�� �(�2��L�V��D�Q��H�T�X�D�O��R�S�S�R�U�W�X�Q�L�W�\��H�P�S�O�R�\�H�U��S�U�R�J�U�D�P���$�X�[�L�O�L�D�U�\��D�L�G�V���V�H�U�Y�L�F�H�V��D�Q�G��R�W�K�H�U��U�H�D�V�R�Q�D�E�O�H��D�F�F�R�P�P�R�G�D�W�L�R�Q�V��D�U�H��T�X�H�V�W��W�R��L�Q�G�L�Y�L�G�X�D�O�V��Z�L�W�K��G�L�V�D�E�L�O�L�W�L�H�V�� �$�X�W�K�R�U�L�W�\���:�R�U�N�H�U�V�¶��'�L�V�D�E�L�O�L�W�\��&�R�P�S�H�Q�V�D�W�L�R�Q��$�F�W��������������������������� �&�R�P�S�O�H�W�L�R�Q���9�R�O�X�Q�W�D�U�\����3�H�Q�D�O�W�\���1�R�Q�H� �:�&������ �5�H�Y�������\f�� �0�L�F�K�L�J�D�Q��'�H�S�D�U�W�P�H�Q�W��R�I��/�D�E�R�U��D�Q�G��(�F�R�Q�R�P�L�F��2�S�S�R�U�W�X�Q�L�W�\��:�R�U�N�H�U�V�¶��'�L�V�D�E�L�O�L�W�\��&�R�P�S�H�Q�V�D�W�L�R�Q��$�J�H�Q�F�\��3�2��%�R�[���������/�D�Q�V�L�Q�J���0�,������� �3�O�D�L�Q�W�L�I�I��1�D�P�H�������������������������������������������� �)�X�O�O��6�R�F�L�D�O��6�H�F�X�U�L�W�\��1�X�P�E�H�U� �$�G�G�U�H�V�V� �'�H�I�H�Q�G�D�Q�W� �V�\f� � �&�D�U�U�L�H�U� �V�\f� If more than one defendant/carrier, also complete and attach Multiple Carrier Redemption Form WC-113A �7�K�H��D�J�U�H�H�P�H�Q�W��W�R��U�H�G�H�H�P��W�K�H��G�H�I�H�Q�G�D�Q�W�¶�V��H�Q�W�L�U�H ��Z�R�U�N�H�U�V�¶��F�R�P�S�H�Q�V�D�W�L�R�Q��O�L�D�E�L�O�L�W�\��I�R�U��L�Q�M�X�U�L�H�V��V�X�V�W�D�L�Q�H�G��E�\��W�K�H��S�O�D�L�Q�W�L�I�I��R�Q�� ����������������� ��K�D�V��E�H�H�Q��F�R�Q�V�L�G�H�U�H�G��E�\��D��0�D�J�L�V�W�U�D�W�H��IT IS ORDERED��W�K�D�W��W�K�L�V��D�J�U�H�H�P�H�Q�W��W�R��U�H�G�H�H�P��W�K�H��G�H�I�H�Q�G�D�Q�W�¶�V��H�Q�W�L�U�H ��O�L�D�E�L�O�L�W�\��I�R�U��Z�R�U�N�H�U�V�¶��G�L�V�D�E�L�O�L�W�\��F�R�P�S�H�Q�V�D�W�L�R�Q��E�H�Q�H�I�L�W�V��E�\��W�K�H��S�D�\�P�H�Q�W��R�I������� ��L�V�� APPROVED DENIED. �0�H�G�L�F�D�O��O�H�I�W��R�S�H�Q��B�B�B�B�B�� �R�Q�O�\��L�I��L�Q�L�W�L�D�O�H�G��E�\��0�D�J�L�V�W�U�D�W�H�\f� IT IS FURTHER ORDERED �W�K�D�W��W�K�H��D�E�R�Y�H��V�X�P��E�H��S�D�L�G��D�V��I�R�O�O�R�Z�V�� ����������������������������������������������3�$�����(���2����)�2�5� �)�H�H�V��� �� �)�H�G�H�U�D�O��,�'��� �(�[�S�H�Q�V�H�V��� �0�(�'�,�&�$�/��3�$��0�(�1�7�6�� �L�Q�F�O�X�G�H��)�H�G�H�U�D�O��,�'��\f� � � � � �2�7�+�(�5��3�$���(���6� � � ������������� �6�W�D�W�H��R�I��0�L�F�K�L�J�D�Q��I�R�U��V�W�D�W�X�W�R�U�\��U�H�G�H�P�S�W�L�R�Q��I�H�H� �&�R�V�W��R�I��D�Q�Q�X�L�W�\���L�I��D�S�S�O�L�F�D�E�O�H� ���3�H�U�V�R�Q�D�O��6�H�U�Y�L�F�H���������� ���0�D�L�O�H�G� � � �'�D�\��R�I� �������������������� �0�D�J�L�V�W�U�D�W�H�� �S�O�H�D�V�H��S�U�L�Q�W�\f� �%�D�O�D�Q�F�H��G�L�U�H�F�W�O�\��W�R��S�O�D�L�Q�W�L�I�I� IT IS FURTHER ORDERED��W�K�D�W��G�H�I�H�Q�G�D�Q�W��U�H�P�L�W��G�H�I�H�Q�G�D�Q�W�¶�V��V�W�D�W�X�W�R�U�\� �U�H�G�H�P�S�W�L�R�Q��I�H�H��R�I����������G�L�U�H�F�W�O�\��W�R��W�K�H��6�W�D�W�H��R�I��0�L�F�K�L�J�D�Q� IT IS FURTHER ORDERED �W�K�D�W��G�H�I�H�Q�G�D�Q�W��V�K�D�O�O��D�O�V�R��F�R�Q�W�L�Q�X�H��W�K�H��S�D�\�P�H�Q�W��R�I� �Z�H�H�N�O�\��F�R�P�S�H�Q�V�D�W�L�R�Q��R�I���� ��S�H�U��Z�H�H�N��W�K�U�R�X�J�K�� �'�R��Q�R�W��Z�U�L�W�H��L�Q��W�K�L�V��D�U�H�D�� Social Security Administration Information The worker is currently age��� and has a remaining life expectancy of ��� years. The net payment of $ ���������������������� is allocated at the rate of $ ��� per month. � �6�L�J�Q�H�G��W�K�L�V��B�B�B�B�B�B�B��G�D�\��R�I� �B�B�B�B����B����B�B�B�B�B�B�B�B�B ������B�B�B�B�B�B�B���&�R�X�Q�W�\��R�I��B�B�B�B�B�B�B�B�B�B�B�B�B�B�B�B�B���0�D�J�L�V�W�U�D�W�H��� ��Q�R�W�L�F�H��R�I��U�H�Y�L�H�Z��R�Q��W�K�H��G�L�U�H�F�W�R�U�¶�V��R�Z�Q��P�R�W�L�R�Q���L�V��Q�R�W��I�L�O�H�G��Z�L�W�K��W�K�H��$�J�H�Q�F�\��Z�L�W�K�L�Q�����G�D�\�V��I�U�R�P���S�H�U�V�R�Q�D�O��V�H�U�Y�L�F�H���R�U��L�I �P�D�L�O�H�G���W�K�H��P�D�L�O�L�Q�J��G�D�W�H��R�I��W�K�L�V��R�U�G�H�U���L�W��V�K�D�O�O��V�W�D�Q�G��D�V��W�K�H��I�L�Q�D�O��G�H�F�L�V�L�R�Q��R�I��W�K�H��:�R�U�N�H�U�V�¶��'�L�V�D�E�L�O�L�W�\��&�R�P�S�H�Q�V�D�W�L�R�Q��$�J�H�Q�F�\�� Payment �of�benefits pursuant to this order and redemption fees are due upon expiration of the appeal period���'�H�Q�L�D�O��R�I��W�K�L�V��D�J�U�H�H�P�H�Q�W��G�R�H�V��Q�R�W��G�L�V�F�K�D�U�J�H���W�K�H��O�L�D�E�L�O�L�W�\��I�R�U��U�H�G�H�P�S�W�L�R�Q��I�H�H�V���6�H�Q�G��R�Q�H��F�R�S�\��R�I� �W�K�L�V��R�U�G�H�U��Z�L�W�K� �\�R�X�U��S�D�\�P�H�Q�W���&�K�H�F�N�V��D�U�H��W�R��E�H��P�D�G�H��S�D�\�D�E�O�H��W�R��W�K�H��6�W�D�W�H��R�I��0�L�F�K�L�J�D�Q��D�Q�G��P�D�L�O�H�G��W�R��:�'�&�$��5�H�G�H�P�S�W�L�R�Q��)�H�H�V���3�2��%�R�[���������/�D�Q�V�L�Q�J���0�L�F�K�L�J�D�Q�������� �'�R��Q�R�W��Z�U�L�W�H��L�Q��W�K�L�V��D�U�H�D�� �(�2��L�V��D�Q��H�T�X�D�O��R�S�S�R�U�W�X�Q�L�W�\��H�P�S�O�R�\�H�U��S�U�R�J�U�D�P���$�X�[�L�O�L�D�U�\��D�L�G�V���V�H�U�Y�L�F�H�V��D�Q�G��R�W�K�H�U��U�H�D�V�R�Q�D�E�O�H��D�F�F�R�P�P�R�G�D�W�L�R�Q�V��D�U�H��D�Y�D�L�O�D�E�O�H��X�S�R�Q��U�H�T�X�H�V�W��W�R��L�Q�G�L�Y�L�G�X�D�O�V��Z�L�W�K��G�L�V�D�E�L�O�L�W�L�H�V�� �$�X�W�K�R�U�L�W�\���:�R�U�N�H�U�V�¶��'�L�V�D�E�L�O�L�W�\��&�R�P�S�H�Q�V�D�W�L�R�Q��$�F�W��������������������������� �&�R�P�S�O�H�W�L�R�Q���9�R�O�X�Q�W�D�U�\����3�H�Q�D�O�W�\���1�R�Q�H� �:�&������ �5�H�Y�������\f��