Final workers compensation: Fill out & sign online

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Click ‘Get Form’ to open the final workers compensation document in the editor.
Begin by entering your Workers' Compensation (WC) number, Claimant's Name, and Social Security Number in the designated fields.
Fill in the Date of Injury and Carrier Claim Number. Ensure these details are accurate as they are crucial for processing your claim.
Next, provide information regarding your Average Weekly Wage and the dates for First Temporary Total Disability (TTD) Payment, Maximum Medical Improvement (MMI), and First Payment of Permanent Partial Disability (PPD).
In the Benefit Summary section, check the boxes for admitted benefits and list their amounts accordingly. This includes Medical to Date, Disfigurement, Vocational Rehabilitation Services, TTD, TPD, and PPD.
If you disagree with any admission of liability or benefit determination, complete the Objection form attached at the end of the document within 30 days.

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