Plaintiff Name Full Social Security Number Address Defendants Carriers If more than one defendantcarrier also complete and attach Multiple Carrier Redemptio ID: 898643
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1 Michigan Department of Licensing and Reg
Michigan Department of Licensing and Regulatory Affairs Workersâ 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 defendantâs entire workersâ compensation liability for injuries sustained by the plaintiff on has been considered by a Magistrate. IT IS ORDERED that this agreement to redeem the defendantâs entire liability for workersâ 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 defendantâs 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 directorâs 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 Workersâ 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: Workersâ Disability Compensation Act 418.835; 418.836; 418.837 Completion: Voluntary; Penalty: None WC-113 (Rev. 4/12) 0LFKLJDQ'HSDUWPHQWRI/DERUDQG(FRQRPLF2SSRUWXQLW\:RUNHUV¶'LVDELOLW\&RPSHQVDWLRQ$JHQF\%RDUGRI0DJLVWUDWHV32%R[/DQVLQJ0, 3ODLQWLII1DPH )XOO6RFLDO6HFXULW\1XPEHU $GGUHVV 'HIHQGDQWV\f &DUULHUV\f If more than one defendant/carrier, also complete and attach Multiple Carrier Redemption Form WC-113A 7KHDJUHHPHQWWRUHGHHPWKHGHIHQGDQW¶VHQWLUH ZRUNHUV¶FRPSHQVDWLRQOLDELOLW\IRULQMXULHVVXVWDLQHGE\WKHSODLQWLIIRQ KDVEHHQFRQVLGHUHGE\D0DJLVWUDWHIT IS ORDEREDWKDWWKLVDJUHHPHQWWRUHGHHPWKHGHIHQGDQW¶VHQWLUH OLDELOLW\IRUZRUNHUV¶GLVDELOLW\FRPSHQVDWLRQEHQHILWVE\WKHSD\PHQWRI LV APPROVED DENIED. 0HGLFDOOHIWRSHQBBBBBRQO\LILQLWLDOHGE\0DJLVWUDWH\f IT IS FURTHER ORDERED WKDWWKHDERYHVXPEHSDLGDVIROORZV 3$(2)25 )HHV )HGHUDO,' ([SHQVHV 0(',&$/3$0(176LQFOXGH)HGHUDO,'\f 27+(53$(6 6WDWHRI0LFKLJDQIRUVWDWXWRU\UHGHPSWLRQIHH &RVWRIDQQXLW\LIDSSOLFDEOH 3HUVRQDO6HUYLFH 0DLOHG 'D\RI 0DJLVWUDWHSOHDVHSULQW\f %DODQFHGLUHFWO\WRSODLQWLII IT IS FURTHER ORDEREDWKDWGHIHQGDQWUHPLWGHIHQGDQW¶VVWDWXWRU\ UHGHPSWLRQIHHRIGLUHFWO\WRWKH6WDWHRI0LFKLJDQ IT IS FURTHER ORDERED WKDWGHIHQGDQWVKDOODOVRFRQWLQXHWKHSD\PHQWRI ZHHNO\FRPSHQVDWLRQRI SHUZHHNWKURXJK 'RQRWZULWHLQWKLVDUHD 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. 6LJQHGWKLVBBBBBBBGD\RI BBBBBBBBBBBBBB BBBBBBB&RXQW\RIBBBBBBBBBBBBBBBBB0DJLVWUDWH QRWLFHRIUHYLHZRQWKHGLUHFWRU¶VRZQPRWLRQLVQRWILOHGZLWKWKH$JHQF\ZLWKLQGD\VIURPSHUVRQDOVHUYLFHRULI PDLOHGWKHPDLOLQJGDWHRIWKLVRUGHULWVKDOOVWDQGDVWKHILQDOGHFLVLRQRIWKH:RUNHUV¶'LVDELOLW\&RPSHQVDWLRQ$JHQF\ Payment of benefits pursuant to this order and redemption fees are due upon expiration of the appeal period'HQLDORIWKLVDJUHHPHQWGRHVQRWGLVFKDUJHWKHOLDELOLW\IRUUHGHPSWLRQIHHV6HQGRQHFRS\RI WKLVRUGHUZLWK \RXUSD\PHQW&KHFNVDUHWREHPDGHSD\DEOHWRWKH6WDWHRI0LFKLJDQDQGPDLOHGWR:&$5HGHPSWLRQ)HHV32%R[/DQVLQJ0LFKLJDQ 'RQRWZULWHLQWKLVDUHD (2LVDQHTXDORSSRUWXQLW\HPSOR\HUSURJUDP$X[LOLDU\DLGVVHUYLFHVDQGRWKHUUHDVRQDEOHDFFRPPRGDWLRQVDUHTXHVWWRLQGLYLGXDOVZLWKGLVDELOLWLHV $XWKRULW\:RUNHUV¶'LVDELOLW\&RPSHQVDWLRQ$FW &RPSOHWLRQ9ROXQWDU\3HQDOW\1RQH :&5HY\f 0LFKLJDQ'HSDUWPHQWRI/DERUDQG(FRQRPLF2SSRUWXQLW\:RUNHUV¶'LVDELOLW\&RPSHQVDWLRQ$JHQF\32%R[/DQVLQJ0, 3ODLQWLII1DPH )XOO6RFLDO6HFXULW\1XPEHU $GGUHVV 'HIHQGDQWV\f &DUULHUV\f If more than one defendant/carrier, also complete and attach Multiple Carrier Redemption Form WC-113A 7KHDJUHHPHQWWRUHGHHPWKHGHIHQGDQW¶VHQWLUH ZRUNHUV¶FRPSHQVDWLRQOLDELOLW\IRULQMXULHVVXVWDLQHGE\WKHSODLQWLIIRQ KDVEHHQFRQVLGHUHGE\D0DJLVWUDWHIT IS ORDEREDWKDWWKLVDJUHHPHQWWRUHGHHPWKHGHIHQGDQW¶VHQWLUH OLDELOLW\IRUZRUNHUV¶GLVDELOLW\FRPSHQVDWLRQEHQHILWVE\WKHSD\PHQWRI LV APPROVED DENIED. 0HGLFDOOHIWRSHQBBBBBRQO\LILQLWLDOHGE\0DJLVWUDWH\f IT IS FURTHER ORDERED WKDWWKHDERYHVXPEHSDLGDVIROORZV 3$(2)25 )HHV )HGHUDO,' ([SHQVHV 0(',&$/3$0(176LQFOXGH)HGHUDO,'\f 27+(53$(6 6WDWHRI0LFKLJDQIRUVWDWXWRU\UHGHPSWLRQIHH &RVWRIDQQXLW\LIDSSOLFDEOH 3HUVRQDO6HUYLFH 0DLOHG 'D\RI 0DJLVWUDWHSOHDVHSULQW\f %DODQFHGLUHFWO\WRSODLQWLII IT IS FURTHER ORDEREDWKDWGHIHQGDQWUHPLWGHIHQGDQW¶VVWDWXWRU\ UHGHPSWLRQIHHRIGLUHFWO\WRWKH6WDWHRI0LFKLJDQ IT IS FURTHER ORDERED WKDWGHIHQGDQWVKDOODOVRFRQWLQXHWKHSD\PHQWRI ZHHNO\FRPSHQVDWLRQRI SHUZHHNWKURXJK 'RQRWZULWHLQWKLVDUHD 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. 6LJQHGWKLVBBBBBBBGD\RI BBBBBBBBBBBBBB BBBBBBB&RXQW\RIBBBBBBBBBBBBBBBBB0DJLVWUDWH QRWLFHRIUHYLHZRQWKHGLUHFWRU¶VRZQPRWLRQLVQRWILOHGZLWKWKH$JHQF\ZLWKLQGD\VIURPSHUVRQDOVHUYLFHRULI PDLOHGWKHPDLOLQJGDWHRIWKLVRUGHULWVKDOOVWDQGDVWKHILQDOGHFLVLRQRIWKH:RUNHUV¶'LVDELOLW\&RPSHQVDWLRQ$JHQF\ Payment ofbenefits pursuant to this order and redemption fees are due upon expiration of the appeal period'HQLDORIWKLVDJUHHPHQWGRHVQRWGLVFKDUJHWKHOLDELOLW\IRUUHGHPSWLRQIHHV6HQGRQHFRS\RI WKLVRUGHUZLWK \RXUSD\PHQW&KHFNVDUHWREHPDGHSD\DEOHWRWKH6WDWHRI0LFKLJDQDQGPDLOHGWR:'&$5HGHPSWLRQ)HHV32%R[/DQVLQJ0LFKLJDQ 'RQRWZULWHLQWKLVDUHD (2LVDQHTXDORSSRUWXQLW\HPSOR\HUSURJUDP$X[LOLDU\DLGVVHUYLFHVDQGRWKHUUHDVRQDEOHDFFRPPRGDWLRQVDUHDYDLODEOHXSRQUHTXHVWWRLQGLYLGXDOVZLWKGLVDELOLWLHV $XWKRULW\:RUNHUV¶'LVDELOLW\&RPSHQVDWLRQ$FW &RPSOHWLRQ9ROXQWDU\3HQDOW\1RQH :&5HY\f