STATE OF MICHIGAN

UIA 1742 Authorized By

(Rev. 02-13) DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY MCL 421.1 et seq.
UNEMPLOYMENT INSURANCE AGENCY
Gretchen Whitmer
GOVERNOR
Jeff Donofrio
DIRECTOR
l
Sent via Go Green

KRISTOPHER A KNOX Mail Date: July 8, 2020

9321 NAVARRE ST # DETROIT Letter ID: L0072151621
DETROIT MI 48214-3037
MIN: 1297441536
Name: KRISTOPHER A KNOX

MEDICAL STATEMENT
This Section must be filled out by the claimant. Return form within ten calendar days from
date to:
Previous work experience and/training working as:
A.________________________________________________ UIA
B.________________________________________________ PO Box 169
C.________________________________________________ Grand Rapids MI 49501-0169
FAX#: (517) 636-0427
D.________________________________________________
E. Other experience/training:____________________
Physician or Institution complete all information below
Physician or Institution
Name: __________________________________________________ Phone Number: (________) _______________
Area Code Number
Address: _________________________________________________________________________________________
No. & Street City State Zip
Patient/Claimant’s Information
Date of First Date of Most Recent
Treatment or Examination: ________________________ Treatment or Examination: ________________________

Limitations:
Are there limitations and/or restrictions to the patient’s ability to work full-time? ............................................YES o NO o
If “YES,” please describe and explain the limitations and/or restrictions. Include the date the limitations began.
Date Limitation(s) Began: _____________________________ Explanation of Limitation(s): _______________________
Ability/Inability to Perform Work:
Is the patient currently able to perform any of the work listed in the boxes labeled A - E above full-time? ....YES o NO o
If “YES,” please indicate which jobs (from choices A - E) patient is able to perform:_______________________________
While under your care, was there a period where the patient was
unable to perform any types of work listed in choices A-E? .......................................................................... YES o NO o

If “YES,” what are the beginnings and ending dates of the

period when the patient was unable to perform the work
shown in choices A-E? Signature____________________________________
Doctor or Institutional Representative
Period of Inability to Work
Beginning Date Ending Date
A. ____________________ A. ____________________ Printed or Type
B. ____________________ B. ____________________ Name_______________________________________
C. ____________________ C. ____________________
D. ____________________ D. ____________________ Date____________________
E. ____________________ E. ____________________

1 UIA is an Equal Opportunity Employer/Program.

l Auxiliary aids, services and other reasonable

accommodations are available upon request to
individuals with disabilities.
UIA 1742 Letter ID: L0072151621
(Rev. 02-13)