New Employee Work Questionnaire Form WC-105A and New Employer Disclosure Questionnaire Form WC-105B

October 30, 2008
 

To:

All Interested Parties in Workers' Compensation Cases
 

From:

Jack A. Nolish, Director, Workers' Compensation Agency


With the excellent cooperation, contributions, assistance and persistence of the State Bar Workers' Compensation Section Executive Committee, Murray Feldman President, I am pleased to provide for your use the WORK HISTORY, WORK QUALIFICATIONS & TRAINING DISCLOSURE QUESTIONNAIRE (form WC-105A) and the EMPLOYER DISCLOSURE QUESTIONNAIRE (form WC-105B).

Issues regarding the use of the questionnaires should be directed to the magistrate assigned to the case.

1.

The questionnaires (forms WC-105A and WC-105B) are available on the Agency website at www.michigan.gov/wca. Both are "fill-in" pdf files that can be downloaded and saved as blank forms. Once filled in, the completed forms can be printed but not saved.*

2.

A limited number will be printed and available at the hearing sites.

3.

Completion of both forms is voluntary.

4.

The questionnaires may be used by the magistrate to facilitate exchange of information as required by Stokes v. Chrysler, LLC, 481 Mich 266 (2008).

5.

The time for use of the questionnaires, including the time for completion, will be determined by the magistrate.

6.

Use of the questionnaires does not limit the magistrates' or the parties' rights to request further disclosure as provided in the Stokes decision.

7.

The questionnaires may be offered as exhibits in a deposition or hearing subject to ruling by the magistrate.

8.

Completed questionnaires should be exchanged among all parties and not sent to the Workers' Compensation Agency.

9.

The questionnaires will not be placed in the Agency file unless admitted as an exhibit at a hearing or as part of a deposition transcript.

10.

Questionnaires mailed to the Agency will be returned and will not be placed in the case file.


It is hoped that these questionnaires will serve as useful tools to assist in the preparation and presentation of proofs as required by the Stokes decision. Again, my thanks to the many practitioners and Agency staff that assisted in the preparation of this form.

*A completed form can be saved if you use the full version of Adobe Acrobat (not Adobe Reader).