MI WC-105A 2019-2025 free printable template

Pointiest All Paperwork HISTORY, WORK QUALIFICATIONS & TRAINING DISCLOSURE QUESTIONNAIRE Michigan Department of Labor and Economic Opportunity Workers Disability Compensation Agency P O Box 30016,

How to fill out history training disclosure questionnaire form

How to fill out MI WC-105A

1. Obtain the MI WC-105A form from the Michigan Workers' Compensation Agency website or your employer.
2. Fill in your personal details in the designated fields, including your name, address, and social security number.
3. Provide information about the accident or illness, including the date, time, and location.
4. Include details of your employer, such as the company name and employer identification number.
5. Describe the nature of your injury or illness and how it occurred.
6. List any medical treatment you have received, including the names of healthcare providers.
7. Sign and date the form to certify that the information is true and correct.
8. Submit the completed form to your employer or the Workers' Compensation Agency as instructed.

Who needs MI WC-105A?

1. Employees who have suffered a work-related injury or illness.
2. Individuals seeking workers' compensation benefits in Michigan.
3. Employers needing to document employee injuries for reporting purposes.

Video instructions and help with filling out and completing 105a work form

Instructions and Help about form 105a blank

Hi I'm Alex Berman I've been practicing workers comp law for over 40 years one question that I hear frequently is regarding mediation what is mediation on when you file an application, or you have a dispute on a worker's comp case, and you try to handle it on your own, and you file it through the state you'll get a mediation hearing that'll be followed by some type of phone conference with a mediator who works for the workers comp agency with probably you on the phone as well as the insurance adjuster usually small claims for medical bills or short periods of time off of work are solved and resolved by mediation that's a good procedure for those cases but if you have a serious injury, and it involves a lot more than just a few medical bills and a short time off you're going to need an attorney because mediation is not going to be very effective for you the insurance companies can't be forced to do anything to pay anything take any action during mediation that can only happen if you go before a magistrate and if you don't succeed in resolving your case in mediation you will be signed to a magistrate for a hearing at that point you definitely need to call us you need an attorney

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What is MI WC-105A?

MI WC-105A is a form used in Michigan for reporting employment and wage information related to workers' compensation claims.

Who is required to file MI WC-105A?

Employers who have had an employee file a workers' compensation claim are required to file MI WC-105A.

How to fill out MI WC-105A?

To fill out MI WC-105A, you need to provide the claimant's personal information, details about their employment, wages, and the nature of their injury, following the instructions provided with the form.

What is the purpose of MI WC-105A?

The purpose of MI WC-105A is to provide detailed information about an employee's earnings and employment status to assist in the adjudication of workers' compensation claims.

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

MI WC-105A must include the employee's name, social security number, dates of employment, hourly wage or salary, and any additional relevant information about the nature of the job and injury.