Employer Disclosure Questionnaire (fill - State of Michigan 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the employee's name and the last four digits of their Social Security Number, followed by their date of birth.
3. In Section 1, provide the full name of the employer, along with the address, city, state, and ZIP code where the employee was employed.
4. Move to Section 2 and detail the employment information. Include dates of employment, wages for each week prior to the alleged injury, and any fringe benefits received.
5. For questions regarding job titles and duties, ensure you provide accurate descriptions and attach any relevant job descriptions if available.
6. Complete all yes/no questions regarding job offers and termination status, providing explanations as necessary.
7. Finally, sign off with the representative’s name, position, and date before exchanging completed forms among all parties involved.

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