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Michigan employer disclosure

Michigan employer disclosure 2026

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The document is an Employer Disclosure Questionnaire from the Michigan Department of Labor and Economic Opportunity, specifically for the Workers’ Disability Compensation Agency. It is designed to collect information regarding an employee's employment details, wages, job duties, and any injuries or disabilities claimed. The completion of the questionnaire is voluntary and aims to facilitate information exchange among parties involved in a workers' compensation case.

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Click ‘Get Form’ to open the Michigan Employer Disclosure in the editor.
Begin by entering the employee's name and the last four digits of their Social Security Number, followed by their date of birth.
In Section 1, provide the full name of the employer, along with the address, city, state, and ZIP code where the employee was employed.
Move to Section 2 and detail the employment information. Include dates of employment and wages for each week prior to the alleged injury. If applicable, attach additional pages for comprehensive details.
Describe any fringe benefits received by the employee during their employment and include relevant records as specified in the form.
Complete all remaining sections regarding job duties, licensing requirements, job offers post-injury, and termination status. Ensure all responses are clear and concise.
Finally, have an employer representative sign and date the form before exchanging it among all parties involved.

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