Employer Disclosure Questionnaire
Download a blank fillable Employer Disclosure Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employer Disclosure Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Reset
Print
EMPLOYER DISCLOSURE QUESTIONNAIRE
Michigan Department of Licensing and Regulatory Affairs
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)
XXX-XX-
Date of Birth
SECTION 1 – EMPLOYER INFORMATION
1. Full name of employer
2. Address of location where employee was employed
3. City
4. State
5. ZIP Code
SECTION 2 – EMPLOYMENT INFORMATION
6. Regarding employee’s employment with employer, provide the following information (attach additional pages as needed):
Dates of employment, inclusive of the last actual day of work.
a.
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.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal