Worker Compensation Form Page 3
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4SECTION 3 – EMPLOYMENT EXPERIENCE
19. List in chronological order each and every job you have had since age 18, including any periods of self-employment, and provide the
information requested. In addition, y ou are to complete one “Job Detail Form” for each job y ou list. If you have had more than five (5) jobs
since age 18, please list the additional jobs on another sheet of paper. You may photocopy the Job Detail Form so that you have one
form for each job you list.
Address if known
Employer
Type of Business
Job Title(s)
Dates of Employment
or City & State
to
1.
to
2.
to
3.
to
4.
to
5.
Please list additional employers on another sheet of paper.
20. Union Employment. Do you now or have you ever worked through or out of a union hall?
Yes
No
If yes, please provide the following information (please attach additional pages if necessary):
Union Name
Local Number
Address if known or City & State
The above information, including any attachments, is true to the best of my knowledge. I understand that the information
disclosed in this questionnaire may be used by the magistrate in determining my entitlement to workers’ compensation
benefits.
Signature of Claimant ____________________________________________ Date ________________________________
(Claimant must sign)
Claimant’s Name _______________________________________________
(Printed or typed)
IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES, PLEASE INCLUDE YOUR FULL NAME AND
THE LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER ON EACH ADDITIONAL PAGE.
Completed forms should be exchanged among all parties and not sent to the Workers’ Compensation Agency.
Authority:
418.205, 418.221, R408.40b(2)
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable
Completion:
Voluntary
accommodations are available upon request to individuals with disabilities.
Penalty:
None
WC-105A (4/12)
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