Worker's Compensation Form - National Elevator Industry Benefit - neibenefits 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Employee Name and ID number in the designated fields at the top of the form.
3. Fill in the Employee Address, ensuring to include all necessary details such as street, city, state, and zip code.
4. In the Attending Physician's Statement section, provide the patient's current diagnosis using ICD-9-CM codes for both primary and secondary conditions.
5. Indicate whether the illness or injury is work-related by selecting 'Yes' or 'No'.
6. Document treatment dates and locations for both office visits and hospital stays.
7. Specify if the patient has been disabled from performing their occupation, including start and end dates of disability if applicable.
8. Complete the physician's information section, including name, degree, specialty, address, telephone number, and taxpayer ID number.
9. Finally, ensure that the physician signs and dates the form to certify accuracy before submission.

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