MICHIGAN ELECTRICAL EMPLOYEES’

HEALTH PLAN
3001 Metro Dr. Suite 500 • Bloomington, MN 55425
(855) 633-4584 • FAX (952) 854-1632
www.michiganelectrical.org

APPLICATION FOR ACCIDENT/SICKNESS WEEKLY DISABILITY BENEFIT

(Note: Participant must complete this side
Reverse side must be completed by your physician)

Name: Date of Birth:

Michael W. Cannon
11/10/1984

Address: 111 Candlewyck Dr Apt # 611 City: State: Zip:

Kalamazoo MI 49001

MID or SS #: Telephone # Local Union #:

311-98-4466 (402) 853-4309 445
Name of Present or Last Employer Current or Last Hourly Wage Amount :
Gurtz Electric Company 38.29
$
Is this claim based on an accident/injury? Yes ✔ No

Nature of sickness or accident/injury:

Distal rupture of the left bicep

Date sickness or accident/injury began: 09/28/2023 Date first treated: 10/11/2023

Did sickness or accident/injury occur in the course of employment? Yes ✔ No

Where did sickness or accident/injury occur?

At work (Pfizer MAPS project 7000 Portage Rd Kalamazoo MI 49002)

How did sickness or accident/injury happen?

I was resetting a disconnect that had tripped and when I went to push up the lever then I felt 3 hard pops in the left arm and a
painful burning sensation in my bicep.

Have you, or do you intend to file this claim under Workers' Compensation? Yes ✔ No

On what date did you last work? 03/15/2024

Have you resumed work? Yes No ✔

If YES, what date:

Date:
03/18/2024
Signature:
 MICHIGAN ELECTRICAL EMPLOYEES’ HEALTH PLAN

ATTENDING PHYSICIAN'S SUPPLEMENTARY STATEMENT

(YOU MUST BE EXAMINED BY A PHYSICIAN AND CERTIFIED AT LEAST EVERY 6-8 WEEKS)

Patient's Name: Date of Birth:

Michael W. Cannon
11/10/1984

Diagnosis and Concurrent Conditions:

Is this claim based on an accident/injury? Yes No

Date sickness or accident/injury began: Date first treated:

Is condition due to injury or sickness arising out of patient's employment? Yes No

If YES, explain:

This patient has been continuously disabled (first day unable to work) from through (last
day unable to work) .

Exact date patient will be able to return to work at trade:

If exact date is unknown, please estimate:

Is patient still under your care for this condition? Yes No

If YES, give date of last treatment:

If YES, give date of next scheduled appointment:

If NO, give date treatment terminated:

Physician's Signature: Date:

Physician's Name (please print) Degree: (check one)

M.D. D.O.
Address:

City: State: Zip:

Telephone Number:
Fax Number: