Voluntary Payment Form {WC-115}

(Personal Service) Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency/Board of Magistrates P.O. Box 30016, Lansing, MI 48909 (Mailed) VOLUNTARY PAYMENT FORM _____ Day of __________ 20 Magistrate (Please print) Plaintiff Plaintiff's Social Security Number Defendant Date of Injury The plaintiff and defendant agree that the plaintiff's Application for Mediation or Hearing is withdrawn. The defendant agrees to pay benefits on a voluntary basis in accordance with the following: $____________________ a. Weekly benefit rate Less benefits to be coordinated Subtotal Plus supplemental benefit TOTAL Benefits to be paid for the period from b. c. d. e. f. Medical expenses to be paid? If yes, to whom? Reimbursement to group carrier? Atty. fee to be charged Yes No Amount $_____________________ Percent ______% Yes $____________________ $____________________ $____________________ $____________________ ____________________ through _________________ No Atty. Fed. I.D.# _____________________________ Amount of interest to be paid $____________________ Additional agreements (attach additional sheets if necessary) Neither the payment of compensation nor the accepting of same by the employee or his/her dependents shall be considered as a determination of the rights of the parties under this Act. All benefits become due and payable on the day of personal service or the mailing date. Plaintiff Defendant Representative of Plaintiff Representative of Defendant Date LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Authority: Completion: Penalty: Magistrate Workers' Disability Compensation Act 408.33(2)(b); 408.40b(3) Voluntary None WC-115 (Rev. 3/14) American LegalNet, Inc. www.FormsWorkFlow.com