Free WORKERS' COMPENSATION AGENCY - Michigan

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EMPLOYER DISCLOSURE QUESTIONNAIRE
Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency PO Box 30016, Lansing, MI 48909

The information disclosed in this questionnaire may be used by the magistrate to facilitate exchange of information as required by Stokes v Chrysler, LLC, 481 Mich 266 (2008). Completion is voluntary. Completed forms should be exchanged among all parties and not sent to the Workers' Compensation Agency. Use of this questionnaire does not limit the parties' rights to request further disclosure as provided in that decision.

Employee Name Social Security Number (last four digits only) SECTION 1 ­ EMPLOYER INFORMATION 1. Full name of employer 2. Address of location where employee was employed 3. City 4. State 5. ZIP Code XXX-XXDate of Birth

SECTION 2 ­ EMPLOYMENT INFORMATION 6. Regarding employee's employment with employer, provide the following information (attach additional pages as needed):
a. Dates of employment, inclusive of the last actual day of work.

b. The employee's wages for each of the 52 weeks prior to the alleged injury/disablement date(s) as well as the last

day employee actually worked. If less than 52 weeks of employment, list wages for all weeks employed.
c. The specific fringe benefits employee received while employed; the employer's cost of any fringe benefits on each

alleged injury/disablement date and the last day employee actually performed work for the employer; and the dates of discontinuance for each fringe benefit identified.

COPIES OF RECORDS TO BE SUBMITTED WITH WRITTEN RESPONSES 7. Regarding the date(s) of the alleged injury/disablement, provide the following information: a. Employee's job title(s) b. The dates on which employee held this title 8. Regarding employee's job duties throughout the entire period of employment with employer, provide a description of the type of work performed by employee, including any supervisory duties, and specific exertional and non-exertional duties actually performed by the employee. Please attach a written job description if one exists.

9. Was employee's job a regular job performed by other non-injured employees Yes of the employer? 10. Describe any licensing, training, or certifications required for the type of employment performed by employee.

No

11. Has the employer made any job offer to the employee after the alleged date(s) of injury?

Yes

No

If yes, a. What were the specific details of the job offered to employee, including the job title and description, the hours and shift offered, the rate of pay offered, the fringe benefits offered, and the locations and distance from employee's residence?

b. When was the job offer made to the employee? c. How was the job offer conveyed to the employee? d. If the job offer was in writing, please provide a copy of the written job offer. 12. Has the employee's employment been terminated? If yes, explain why If no, explain why the employee stopped working for the employer. Yes No

I have provided, or will provide as soon as they become available, copies of all existing medical, employment and personnel records that are relevant to this claim to either the injured worker (if unrepresented), the injured worker's counsel, or employer's counsel.

Signature of employer's representative (Not counsel for employer) Representative's name
(Printed or typed)

Position

Date

Completed forms should be exchanged among all parties and not sent to the Workers' Compensation Agency.
Authority: Completion: Penalty: 418.205, 418.221, R408.40b(2) Voluntary None

DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-105B (3/09) www.michigan.gov/wca