Instructions For Notice Of Compensation Payments Form With Examples {BWC-701}

Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 PART A 1. Social Security Number 6. Employee Street Address 10. Employer Name 13. Employer Street Address 17. Carrier or Self-Insured Name 19. Self-Insurer's Service Company Name 21. ZIP Code of Issuing Office 22. Carrier or Self-Insured Claim Number 23. Date Carrier Received Notice of Injury 14. City 2. Date of Injury 3. Employee Name (Last, First, MI) 7. City 4. Date of Birth 8. State 11. Federal ID Number 15. State NOTICE OF COMPENSATION PAYMENTS FILING # ________ 5. Date of Death 9. ZIP Code 12. Injury Location Code 16. ZIP Code N/A 18. NAIC or Self-Insured Number 20. Service Company ID Number 24. Date First Payment Made PART B 25. Nature of Injury 27. Average Weekly Wage 28. Discontinued Fringes 26. Part of Body 29. Second Employer A.W.W. 30. Second Employer Discontinued Fringes $ 31. Tax Filing Status on Date of Injury $ 32. Last Day Worked $ 33. Number of Days in Work Week $ 34. Number of Dependents PART C 35. Reason for Filing 36. Weekly Compensation Base Rate $ 37. Weekly Adjustments to Base Rate $ $ $ $ $ $ $ $ $ $ $ 38. Weekly Amount Being Reimbursed by a Fund (Not reported on Line 37) $ BENEFIT TYPE SPECIAL PAYMENT TOTAL WEEKLY RATE PART D BASIS OF PAYMENT FROM THROUGH TOTAL AMOUNT PAID YEAR PAID TERMINATION REASON IF BASIS OF PAYMENT IS OTHER THAN "A" (VOLUNTARY PAYMENT) OR LINE 37 IS EQUAL TO "J" OR "K," ENTER ORDER # IF BENEFIT TYPE IS "C" (SPECIFIC LOSS), ENTER NUMBER OF WEEKS ________ AND EFFECTIVE DATE OF LOSS IF ANY FILING CODES ON THIS FORM REPRESENT "OTHER," PLEASE BE SPECIFIC 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. THIS IS TO CERTIFY THAT A COPY OF THIS FORM HAS BEEN MAILED OR GIVEN TO THE EMPLOYEE 39. Authorized signature 40. Person Handling Claim (Please Print) 41. Telephone Number 42. Date NOTICE TO EMPLOYEE: IF ANY OF THE ABOVE INFORMATION IS INCORRECT, PLEASE CONTACT THE INDIVIDUAL NAMED IN LINE 40. WC-701 (Rev. 2/13) Front American LegalNet, Inc. www.FormsWorkFlow.com PART E ­ COORDINATION OF BENEFITS PENSION A. WEEKLY BENEFIT AMOUNT B. 80% AFTER-TAX AMOUNT OF (A) x 1.25 C. 100% AFTER-TAX AMOUNT D. FICA TAX1 E. STATE INCOME TAX1 F. % EMPLOYER CONTRIBUTION G. INCOME TO BE COORDINATED2 1 WAGE CONTINUATION DISABILITY INSURANCE SELF INSURANCE OTHER x 1.25 x 1.25 x 1.25 x 1.25 Does not apply in all cases. If applicable, include the value of FICA and state income tax using the figures provided in the back of the agency's rate tables corresponding to the year of injury. Line G = (Line C + D + E) x Line F. (This figure should appear in Part C, Line 37, with the appropriate adjustment code) (Enter net benefit with code "B" in Part C, Line 37) 2 SOCIAL SECURITY This section applies to old age retirement benefits only. A. B. C. D. E. MONTHLY SOCIAL SECURITY OLD AGE RETIREMENT AMOUNT WEEKLY SOCIAL SECURITY OLD AGE RETIREMENT AMOUNT (Line A divided by 4.33) 50% OF LINE B 50% OF THE WEEKLY BENEFIT RATE PAYABLE IS DATE OF INJURY ON OR AFTER 12/19/11? IF NO ­ COORDINATE AMOUNT IN LINE C YES NO IF YES ­ WERE SOCIAL SECURITY OLD AGE RETIREMENT BENEFITS BEING PAID ON THE DATE OF INJURY? IF NO ­ COORDINATE AMOUNT IN LINE C IF YES ­ COORDINATE THE LOWEST AMOUNT FOUND IN LINE C OR D YES NO UNEMPLOYMENT COMPENSATION A. B. C. D. NUMBER OF WEEKS AWARDED BEGINNING DATE OF UNEMPLOYMENT COMPENSATION SCHEDULED EXPIRATION DATE TOTAL WEEKLY UNEMPLOYMENT COMPENSATION BENEFITS (Enter with code "D" in Part C, Line 37) PART F ­ RATE ADJUSTMENT3 FOR POST INJURY WAGE EARNING CAPACITY (PIWEC) (MCL 418.301(8) & 401(6)) A. B. C. D. E. F. AVERAGE WEEKLY WAGE 80% AFTER-TAX AMOUNT OF LINE A (See calc program or rate charts) 100% AFTER-TAX AMOUNT (Line B multiplied by 1.25) GROSS WEEKLY POST INJURY WAGE EARNING CAPACITY (PIWEC) AMOUNT DIFFERENCE BETWEEN 100% AFTER-TAX AMOUNT AND PIWEC (Line C minus Line D) If the calculation in line E is less than or equal to $0, report base rate as adjustment amount in G. 80% of Line E (Line E multiplied by .8)3 G. AMOUNT OF ADJUSTMENT FOR PIWEC (Base rate from front, Line 36, minus Line F) This figure should appear on front, Part C, Line 37, with appropriate adjustment code R. If the adjustment calculation shows an amount that is less than or equal to $0, no adjustment can be applied. 3 For injury dates on or after 12/19/11, the weekly benefit rate payable is 80% of the difference between the injured employee's after-tax average weekly wage before the personal injury and the employee's wage earning capacity after the personal injury but not more than the maximum weekly rate determined under section 355. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-701 (Rev. 4/13) Back Authority: Completion: Penalty: Workers' Disability Compensation Act, R408.31(6a-d) Mandatory Workers' Disability Compensation Act, 418.631; 418.801 American LegalNet, Inc. www.FormsWorkFlow.com