Michigan's workers' compensation agency uses this chart to document the exact level of an amputation for specific-loss benefits. On the diagram the operating surgeon marks the point of amputation and, for an arm or leg, the distance below the elbow or knee, then adds remarks and signs a certification. The insurance carrier or service agent files it with the Workers' Disability Compensation Agency.
Only the operating surgeon completes the chart: the diagram, the remarks and the certification with signature.
Download the current version from the source each time; forms change without notice.
Amputation Chart
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Only the operating surgeon. The form is limited to the surgeon who performed the amputation, who marks the point of amputation on the diagram, records the distance below the elbow or knee for a limb, adds remarks and signs the certification.
Back to the insurance carrier or its service agent, which files it with Michigan's Workers' Disability Compensation Agency. The carrier also reports compensation payments to the Agency on its own forms, such as WC-701, Notice of Compensation Payments.