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Trouble? Fax or mail to:
MML Workers’ Compensation Fund MML Claims, Fax: 616-942-0390
SHORT FORM 3501 Lake Eastbrook, SE, Suite 150
Grand Rapids, MI 49546-5939
EMPLOYER’S REPORT OF INJURY
To be completed for a claim of disability OSHA LOG CASE #
that does not exceed seven (7) days or
for a claim of medical expense only.
Full Name Soc Sec No.
(First, Middle Initial, Last) Male Female
Street City State Zip
Employee Date of Birth Marital Dependents
Occupation Employee Date of Hire
Date of Time of AM Time employee AM City + ZIP CODE
Injury Injury PM began work PM Where Injury Occurred
What kind of injury? (contusion, Body Part Injured
cut, fracture, sprain, strain, etc.)
How did injury occur?
What was employee doing just
before incident occurred?
Die Yes No
Last Day Worked Date Returned If yes,
No Time Lost to Work what date?
Was employee treated in an Was employee hospitalized Case No. from
Emergency Room? Yes No overnight as an in-patient? Yes No Hospital Log
Name Federal ID#
(Required by BWC)
Location of Accident
(if different from mailing address)
Contact Telephone Date Injury Was
Reported to Employer
Preparer’s Name Date
Preparer’s Title Preparer’s Email Address