Name
Michigan Catholic Conference
Phone
(800) 395-5565
Fax
(517) 372-3940
Address
510 S. Capitol Ave.
Lansing, MI 48933

Workers’ Compensation Employee Report of Injury Form

In the event of an injured employee, Workers’ Compensation Employee Report of Injury Form must be filled out in its entirety to ensure proper handling. Once the form is filled out, it must be sent to Gallagher Bassett Services, Inc. to be processed.

The preferred way to submit all WC forms is by direct fax to:

517-351-5528 Attn: Tyler

The other option is to email it to:

Tyler_Drouare@gbtpa.com

If neither of those options are available, please mail the completed form to:

Tyler Drouare
300 W. Lake Lansing Rd.
East Lansing, MI 48823

If you have any questions about the form or the incident, contact Tyler at Gallagher Bassett Services at 517-318-8109.

Reminder: Send the completed form directly to Tyler Drouare at the Gallagher Bassett Services office so he can review it and verify the information. He will then forward it to the State of Michigan Workers’ Compensation Agency accordingly.

The form is located on the State of Michigan’s website.

Name
Michigan Catholic Conference
Phone
(800) 395-5565
Fax
(517) 372-3940
Email
Address
510 South Capitol Avenue
Lansing, Michigan 48933
Multiple People Add Symbol Arrow Pointing Upward Two Arrows Forming a Circle Federal Building Chat Bubble Catholic Church Clipboard and Checkmark Clipboard and Plus Sign Office Building Envelope Person's Face Paper Document Flag Waving Lightning Bolt Person Raising Their Hand Key Hamburger Menu Icon Newspaper Clipping Graduation Cap Magnifying Glass Dollar Sign Five-Point Star Speech Bubbles