Form 105a form 2026

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4.3 out of 5

146 votes

The document is a Work History, Work Qualifications & Training Disclosure Questionnaire from the Michigan Department of Licensing and Regulatory Affairs, intended for individuals seeking workers' compensation benefits. It collects personal information, educational background, employment history, and skills to assist in determining entitlement to benefits. The completion of the form is voluntary and should be exchanged among parties involved.

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Click ‘Get Form’ to open the form 105a in the editor.
Begin with Section 1 – General Information. Fill in your name, last four digits of your Social Security Number, and address details including city, state, and ZIP code.
Indicate whether you have a valid driver’s license or government-issued photo ID. If applicable, provide the issuing state and expiration date.
Move to Section 2 – Educational/Vocational/Military Background. Complete questions regarding your education level, high school graduation status, and any disabilities that may affect employment.
In Section 3 – Employment Experience, list all jobs held since age 18. Ensure to complete a Job Detail Form for each position listed.
Review all sections for accuracy before signing at the end of the form. Make sure to include your printed name and date.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (100 Votes)
2012	4.3 Satisfied (146 Votes)

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