Worker Compensation Form Page 4
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4JOB DETAIL FORM
Please complete one Job Detail Form for each job listed in Section 3, question 19.
JOB # __________________
Employer’s Name (include any self-employment)
Employer’s Street Address
City
State
ZIP Code
Dates of Employment
Rate of Pay $ _______________ per
Hour
Day
Week
Month
Year
Hours per day ____________________________
Days per week _______________________________
Describe this job. In this job, how many total hours each day did you:
Walk ________
Stand ________
Sit ________
Climb ________
Reach ________
Stoop
________
Crawl
________
(Bend down & forward at waist)
(Move on hands & knees)
Kneel
________
Handle, grab or grasp big objects
________
(Bend legs to rest on knees)
Crouch
________
Write, type or handle small objects
________
(Bend legs & back down & forward)
Lifting and Carrying. Explain what you lifted, how far you carried it, and how often you did this.
Check the heaviest weight lifted:
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
100 lbs. or more
Other __________
Check weight you frequently lifted:
(By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs.
10 lbs.
25 lbs.
50 lbs. or more
Other __________
Did this job require you to work with the public?
Yes
No
If yes, describe:
Did this job require you to use machines, tools or equipment?
Yes
No
If yes, describe:
Did this job require you to use technical knowledge or skills?
Yes
No
If yes, describe:
Did this job require you to perform any duties such as writing, completing reports, etc.?
Yes
No
If yes, describe:
Did this job require you to supervise other people?
Yes
No
If yes, describe:
Signature of Claimant ____________________________________________ Date ________________________________
(Claimant must sign)
Claimant’s Name _____________________________________
Social security number XXX-XX-_______________
(Printed or typed)
(Last four digits)
WC-105A (4/12)
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