Understanding Workers’ Comp Form WC-104A

If you were injured on the job, you may be entitled to injured worker benefits under Michigan’s workers’ compensation laws. If you applied and received a denial, don’t give up. You have a right to appeal.

It’s at that stage in the process – when you’re appealing a claim – that you’ll need to learn about Form WC-104A.


First, make sure you understand the basics of the system.

Workplace injuries affect workers in any industry. Under Michigan law, employers must purchase workers’ compensation insurance policies or get approval to self-insure so they can provide benefits to workers injured on the job.

According to Bureau of Labor Statistics numbers for 2015, workers ages 45-54 spent a larger number of days away from work due to workplace injuries than any other group.

If you suffer a work-related injury or illness at any age, your employer’s insurance policy should pay for expenses related to medical care, wages lost after the first seven days and rehabilitation services.

Your employer should submit a claim form with the Workers’ Compensation Agency. Alternatively, if your employer won’t file the form, you may do so using Workers’ Comp Form WC-117 (“Employee’s Report of Claim”).


If the insurance company – or your employer if your employer self-insures – disputes the claim, you have the right to appeal the decision by filing form WC-104A (Application for Mediation or Hearing).

This form will ask you to provide basic information about yourself, your dependents and your employer. You’ll give information related to your dates of employment and your compensation.

It’s important to provide specific information about your work-related injury, including the city and county where the injury occurred and the date, or dates, you were injured or became ill at work.

Describe the nature of your injury in as much detail as possible. Explain how it happened and what relief you feel you should receive under workers’ compensation laws.

The form includes a series of “yes/no” questions, as well as questions about other benefits you may have been receiving during the period of injury or disability.

It will also ask you to supply the names and addresses of hospitals, clinics, doctors or other health care providers who treated you for your work-related health problems.

Finally, if anyone witnessed the injury, you’ll need to provide that information.

For witnesses who still work for your employer, don’t include names or contact information. It’s enough just to indicate whether you intend to call one or more current employees as witnesses.

While Form WC-104A looks fairly simple, the way you answer its questions can mean the difference between having your appeal approved or denied.

It’s essential that you understand what the questions are asking and provide complete responses.


It’s important to contact an experienced workers’ compensation attorney quickly to get the details right and protect your rights under the law.

If you choose not to work with a lawyer, you may not get all of the benefits you should. When you hire a workers’ comp attorney, you have someone in your corner working for you, not for your employer’s insurance company.

The experienced, knowledgeable attorneys at Levine Benjamin can help you with workers’ compensation claims or appeals — and Social Security Disability applications and appeals when that applies.

Contact us today to schedule a free consultation.


Michigan Workers’ Compensation Agency

Bureau of Labor Statistics

Rights and Responsibilities under Michigan’s Workers’ Compensation Program

U.S. Department of Labor Office of Workers’ Compensation Programs

Category: Workers' Comp
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