How to Fill Out a Michigan Household Services Statement Form Video

If you’ve been injured in an auto accident, understanding how household services benefits work is essential. These benefits help cover everyday tasks you can no longer perform on your own while you recover.

Michigan’s no-fault laws can be complicated, especially when it comes to documenting household services. An experienced car accident attorney can help explain your options and make sure your forms are completed correctly.

Filling out a household services statement form involves several important steps, including:

• Listing the specific household tasks that were performed on your behalf
• Identifying who provided the services • Recording the dates the services were completed
• Documenting the amount charged per day, up to the allowable limit
• Signing and keeping consistent records to support your claim

It’s also critical to stay organized. Incomplete or inaccurate forms can lead to delays or denials of your household services benefits, so documentation should be maintained and submitted regularly. This video will teach you how to fill out a Michigan household services statement form.

Click here for a Printable Michigan Household Services Statement Form.

Michigan’s no-fault law provides payment of household services if you require assistance with household chores due to injuries suffered in the crash. This includes assistance with cooking, laundry, yard work, driving, and other needs. Your family member, neighbor, or even a hired person can get paid for providing these services while you recover from your injuries.

To qualify for these benefits, you need a doctor’s certificate stating you need this assistance.

Step one

First, you need to fill in your name and the no-fault insurance claim number. You should have the claim number in a letter you received from the adjuster.

Step two

Second, fill in the name of the person who provided the services to you. Also, put in their address, telephone number, and social security number. The social security number is required so the insurance company can issue payment to the household service provider.

Step three

The next step is filling out the calendar chart to list the services that were provided on specific dates. The form has a list of services with each being assigned a letter. For example, the chore of vacuuming is assigned letter A, and laundry is assigned letter G. First, write the month and year on the form.

You must complete a new form each month and submit it to the insurance adjuster after the month ends. If on the first day of the month your family member provided services of cooking, dishwashing, and vacuuming, you’ll write CDA in the date one box. If on the second day of the month, your family members provide services of cooking, dishwashing, and dusting, you’ll write CDA in the date two box.

You must fill out the date boxes for each day of the month that you receive services. You may have the same services provided daily, like cooking and making beds, and other services provided just a few times a month, like lawn care or shoveling snow. Remember, the most you can receive on a single day for services is $20, regardless of whether there are many services provided on that day. This is determined by Michigan law.

Step four

Finally, the forms must be signed and dated by the service provider on the signature line. You should then make a copy to keep as proof and send the original to the insurance adjuster for payment. You should be paid within 30 days of submitting your claim.

Contact Buckfire Law For Help Filling Out Your Household Services Statement Form

This video should help you with filling out this form, but feel free to call your lawyer or case manager at the Buckfire Law Firm if you have any questions.  If you do not have a lawyer and need assistance filing your insurance claims, call us now so we can help you every step of the way.