How to Fill Out Workers’ Compensation Form WC-104A in Detroit

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You were injured on the job. You should be able to receive injured worker benefits under Michigan’s workers’ compensation laws. But then you get denied.

Don’t give up. You have a right to appeal. You still have a chance to get the medical coverage and checks for lost wages that you need to put your life back on track.

And when you’re appealing a workers’ comp denial—you’ll need to complete Form WC-104A.

Application for Mediation or Hearing

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You should receive medical care and lost wages coverage from Michigan workers’ comp after you’re hurt at work.

What Should Workers’ Comp Provide in Michigan?

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 take care of workers injured on the job.

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

You can also get counseling and training to help you return to the workforce, but proceed with caution—those services are often a way for insurers to end your benefits before you’re ready.

Your employer should have started your claim by submitting a form with the state Workers’ Compensation Agency. Or, if your employer wouldn’t cooperate, you could have filed your claim yourself using Workers’ Comp Form WC-117 (“Employee’s Report of Claim”).

How to Fill Out FORM WC-104A

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

This form asks you for basic information on these points:

  • Your employer’s name and location
  • Your dates of employment
  • Your compensation
  • Where your injury occurred
  • When your injury occurred
  • Witnesses who saw your accident
  • Names of doctors or other medical providers you’ve seen
  • Names of hospitals and clinics where you’ve gone
  • Whether you’re receiving any other form of disability benefits
  • Your tax filing status
  • Your dependents

It’s important to provide specific, complete information about your work-related injury. Describe it in as much detail as possible.

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 make the difference between getting denied again and finally winning workers’ compensation.

You can call a lawyer who will take care of all your required workers’ comp forms.

Get Help with Form WC-104A

As soon as you learn your benefits are being denied or cut off, it’s important to contact an experienced workers’ comp attorney quickly.

An attorney can help you 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.

The workers’ comp insurance company has its own lawyers and looks out for its own best interests—not yours.

When you have a lawyer, you have someone in your corner working for you.

To get every kind of workers’ comp or disability income available to you, look to a law firm that’s helped 50,000 people win benefits.

Work with an Experienced Lawyer

The knowledgeable attorneys at Levine Benjamin Law Firm can help you with workers’ compensation claims or appeals—and Social Security Disability—applications and appeals if your health problems qualify you for that type of benefits.

We’ve helped more than 50,000 people win disability benefits since 1964.

We don’t charge any attorney fee until you win workers’ comp. And we evaluate your case for FREE.

From applying to appealing, we help you every step of the way.