MI WC-105A 2012 free printable template
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Print Reset All Pages WORK HISTORY, WORK QUALIFICATIONS & TRAINING DISCLOSURE QUESTIONNAIRE Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency P O Box 30016, Lansing,
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How to fill out MI WC-105A
01
Obtain the MI WC-105A form from the Michigan Workers' Compensation Agency website or your employer.
02
Fill out your personal information in the designated fields, including your name, address, and Social Security number.
03
Provide details about the injury or illness, including the date it occurred and how it happened.
04
List the names of all healthcare providers you have seen for this injury or illness.
05
Include any additional information or comments in the sections provided, if necessary.
06
Review the completed form for accuracy and completeness.
07
Sign and date the form.
08
Submit the form to your employer or the appropriate worker's compensation insurance carrier.
Who needs MI WC-105A?
01
Employees who have suffered a workplace injury or illness and are seeking workers' compensation benefits.
02
Employers who need to collect necessary information from employees to process a workers' compensation claim.
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What is MI WC-105A?
MI WC-105A is a form used in Michigan for reporting workers' compensation claims and claims information.
Who is required to file MI WC-105A?
Employers who have employees receiving workers' compensation benefits are required to file MI WC-105A.
How to fill out MI WC-105A?
To fill out MI WC-105A, the employer must provide information such as the injured employee's details, the nature of the injury, the date of the incident, and any related medical information.
What is the purpose of MI WC-105A?
The purpose of MI WC-105A is to ensure accurate reporting and documentation of workers' compensation claims in Michigan.
What information must be reported on MI WC-105A?
MI WC-105A must report the employee's personal information, details of the injury, the date of injury, the employer's information, and any medical treatment provided.
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