MI WC-105B 2019-2025 free printable template
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ResetPrintEMPLOYER DISCLOSURE QUESTIONNAIRE
Michigan Department of Labor and Economic Opportunity
Workers Disability Compensation Agency
PO Box 30016, Lansing, MI 48909The information disclosed in
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How to fill out MI WC-105B
01
Download the MI WC-105B form from the Michigan state website or obtain a physical copy.
02
Fill in your personal information at the top of the form, including your name, address, and contact details.
03
Provide details about your employer, including their name, address, and contact information.
04
Describe the injury or illness that occurred, including the date it happened and the nature of the injury.
05
Include information about any medical treatment received, such as the names of doctors or medical facilities.
06
Sign and date the form to validate the information provided.
07
Submit the completed form to the appropriate workers' compensation agency or your employer as instructed.
Who needs MI WC-105B?
01
Workers who have sustained an injury or illness related to their job.
02
Employers required to report work-related injuries to appropriate authorities.
03
Insurance companies that process workers' compensation claims.
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What is MI WC-105B?
MI WC-105B is a form used in Michigan workers' compensation cases to report an employee's injuries and the details surrounding their claim.
Who is required to file MI WC-105B?
Employers in Michigan who have an employee that sustains a work-related injury or illness are required to file the MI WC-105B form.
How to fill out MI WC-105B?
To fill out MI WC-105B, employers must provide details about the employee, the nature of the injury, the date it occurred, and any medical treatments that have been provided.
What is the purpose of MI WC-105B?
The purpose of MI WC-105B is to formally notify the Michigan Workers' Compensation Agency of an employee's injury and the claim for compensation.
What information must be reported on MI WC-105B?
Information that must be reported on MI WC-105B includes the employee's name, address, date of birth, date of the injury, nature of injury, and medical treatment details.
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