1. Social Security Number 2. Date of injury 3. Employee name (Last, First, MI)
EMPLOYER'S BASIC REPORT OF INJURY
Michigan Department of Labor and Economic Opportunity
Workers’ Disability Compensation Agency
PO Box 30016, Lansing, MI 48909
An employer shall report immediately to the agency on Form WC-100 all injuries, including diseases, which arise out of and in the course of the employment, or on which a claim is
made
employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures.
and result in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific losses. In case of death, an
I. EMPLOYEE DATA
4. Address (Number & Street) 5. City 6. State 7. ZIP Code
8. Date of birth (MM/DD/YYYY)
10. Number of dependents
11. Telephone number
12. Tax filing status: A. Single B. Single, Head of Household C. Married, Filing Joint D. Married, Filing Separate
II. EMPLOYER/CARRIER DATA
14. Federal ID Number 13. Employer name
18. Type of business (SIC/NAICS) 17. UI number
16. Mailing location code
15. Injury location code
22. ZIP code
21. State 20. City
19. Employer street address
24. Insurance company telephone number (if known)
23. Insurance company name (if employer not self-insured)
III. INJURY/MEDICAL DATA
26. Date employee returned to work (if applicable)
25. Last day worked
28. If yes, date of death
27. Did employee die?
Yes No
29. Injury city
31. Injury county
35. Time of event
33. Case number from OSHA/MIOSHA log
34. Time employee began work
a.m. p.m.
a.m. p.m.
If time cannot be determined,
check here
36. What was the employee doing just before the incident occurred? 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 ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during replacement”
39. Part of body directly affected by the injury or illness
38. Describe the nature of 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?
Yes No
43. Was employee hospitalized overnight as an in-patient?
Yes No
44. If treatment was given away from the worksite, where was it given? (Include name, address, city, state and ZIP code of facility)
IV. OCCUPATION AND WAGE DATA
47. Number of weeks used
46. Total gross weekly wage (highest 39 of 52) 45. Date hired
48. Value of discontinued fringes
49. Occupation (Be specific)
51. Was employee certified as vocationally handicapped?
50. Was employee a volunteer worker?
Yes No
Yes No
53. If temporary service agency, provide name/address of employer where injury occurred.
52. Date employer notified by employee
V. PREPARER DATA I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE
Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits.
56. Telephone number 55. Preparer's signature
54. Preparer's name (Please print or type)
57. Date prepared
Notice to employee: Questions or errors should be reported immediately to the individual listed above in space 54
WC-100 (Rev. 08/19) Front
Male Female
9. Sex
32. Did injury occur on employer's premises?
Yes No
30. Injury state
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OCR 100
If you are using this form as a replacement for the Form 301 to document the specifics of an injury or ill ness for
purposes of compliance with the work-related injury and illness logging requirements, follow the instructions in
Section A only.
If you are using this form to report a workers’ compensation injury, follow the instructions in Section A and B.
Section A
This form can be used in lieu of the MIOSHA Form 301, Injury and Illness Incident Report. It is one of the first
forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of
Work-Related Injuries and Illnesses (Form 300) and the accompanying Summary (Form 300A), these forms help
the employer and MIOSHA develop a picture of the extent and severity of work-related incidents.
Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred,
you must fill out questions 2-9, 27-28, 33-45 and 54-57.
According to Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974,
Part 11, Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, you must keep this
form on file for 5 years following the year to which it pertains.
DO NOT mail this form to the Workers’
Disability Compensation Agency unless it meets the conditions listed below in Section
B.
Section B
Authority: Workers' Disability Compensation Act, 408.31(1)(3)
Completion:
Mandatory
Penalty: Workers' Disability Compensation Act, 418.631
You must complete all questions on this form if the injury or disease results in any of the following: (a) Disability
extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific loss. The
original form must be mailed to the Workers’ Disability Compensation Agency, P.O. Box 30016, Lansing, MI
48909.
LEO is an equal opportunity employer/program. Auxiliary aids,
services and other reasonable accommodations are available upon
request to individuals with disabilities.
WC-100 (Rev. 08/19) Back
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