Employer request 2026

1. Click 'Get Form' to open the employer request in the editor.
2. Begin by entering the WCB Case Number, Carrier Case Number, and Carrier Code in the designated fields. This information is crucial for tracking your request.
3. Fill in the Date of Injury using the provided format (mm/dd/yyyy). Ensure accuracy as this date is significant for processing your request.
4. Complete the Claimant's Name and Social Security Number fields. This identifies the individual involved in the case.
5. Specify the District Office where notices should be sent. This ensures that all communications are directed appropriately.
6. In Section 11, check all applicable reasons for your request. Provide detailed explanations if necessary, especially if you are requesting a reduction or suspension of payments.
7. Attach any relevant medical or payroll evidence supporting your position. Use our platform’s upload feature to easily add these documents.
8. Finally, certify that a copy of this form has been submitted to all parties involved by signing and dating at the bottom of the form.

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