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Form Bwc-100 - Michigan Workers' Compensation Employer'S Basic Report Of Injury Instructions

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If you are using this form as a replacement for the Form 301 to document the specifics of an injury or

illness 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 rec ordable 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 1-9, 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,

DO NOT mail this

you must keep this form on file for 5 years following the year to which it pertains.

form to the Bureau of Workers’ & Unemployment Compensation unless it meets

the conditions listed below in Section B.

Section B

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 Bureau of Workers’ & Unemployment

Compensation, P.O. Box 30016, Lansing, MI 48909.

The

Department of Consumer & Industry Services will not

discriminate against any individual or group because of race,

Authority:

Workers' Disability Compensation Act, 408.31(1)(3)

sex, religion, age, national origin, color, marital status,

Completion:

Mandatory

disability, or political beliefs. If you need assistance with

Penalty:

Workers' Disability Compensation Act, 418.631

reading, writing, hearing, etc., under the Americans with

Disabilities Act, you may make your needs known to this

agency.

BWC-100 (06/02) Back

Form Bwc-100 - Michigan Workers' Compensation Employer'S Basic Report Of Injury Instructions