Employer Disclosure Questionnaire Page 2

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9. Was employee’s job a regular job performed by other non-injured employees
Yes
No
of the employer?
10. Describe any licensing, training, or certifications required for the type of employment performed by employee.
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?
Yes
No
If yes, explain why
If no, explain why the employee stopped working for the employer.
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
Position
(Printed or typed)
Date
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-105B (4/12)

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