Partial disability form 2026

1. Click ‘Get Form’ to open the partial disability form in the editor.
2. Begin by entering your WC Claim Number, Employee Name, and Social Security Number in the designated fields. This information is crucial for identifying your claim.
3. Fill in the Employer Name and Injury Date. Ensure accuracy as this data impacts your compensation calculations.
4. In the section for Temporary Partial Disability (TPD), enter each week’s ending date and the hours worked during that week. Remember to include any hours lost during the waiting period as hours worked.
5. Input your hourly rate in the corresponding field, then calculate and enter your wages earned by multiplying hours worked by your hourly rate.
6. Next, provide your weekly wage at the time of injury and calculate wage loss by subtracting wages earned from this amount.
7. Calculate the percentage of wage loss and input it into the form. Finally, determine your TPD payment based on these calculations.

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