MI WC-105B 2012 free printable template

Print Reset EMPLOYER DISCLOSURE QUESTIONNAIRE Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 The information disclosed in this

How to fill out MI WC-105B

How to fill out MI WC-105B

1. Obtain the MI WC-105B form from the Michigan Department of Licensing and Regulatory Affairs website or your employer.
2. Fill in your personal information such as name, address, and contact details in the designated fields.
3. Provide your Social Security number, if required.
4. Specify the date of your injury or illness and describe the nature of the injury in the provided section.
5. Complete the employer information section, including the name and address of your employer.
6. Indicate the type of benefits you are claiming (e.g., medical, wage loss).
7. Sign and date the form to certify that the information provided is accurate.
8. Make copies of the completed form for your records before submitting it to the appropriate agency.

Who needs MI WC-105B?

1. Individuals who have suffered a work-related injury or illness in Michigan and are seeking workers' compensation benefits.
2. Employers who need to report work-related injuries or illnesses to their injured employees.

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What is MI WC-105B?

MI WC-105B is a form used in Michigan to report an employee's injury that occurred on the job and to provide information regarding the workers' compensation claim.

Who is required to file MI WC-105B?

Employers who have workers' compensation insurance in Michigan are required to file MI WC-105B when an employee is injured and seeks medical treatment or misses work due to the injury.

How to fill out MI WC-105B?

To fill out MI WC-105B, complete the required sections including the employee's information, details of the injury, and any medical treatment received. Ensure that the form is signed and dated by the employer or the authorized representative.

What is the purpose of MI WC-105B?

The purpose of MI WC-105B is to notify the Michigan Workers' Compensation Agency about an employee's work-related injury, to ensure compliance with reporting requirements, and to facilitate the processing of the workers' compensation claim.

What information must be reported on MI WC-105B?

The information that must be reported on MI WC-105B includes the employee’s name, date of injury, location of injury, nature of the injury, any medical treatment received, and the employer's information.