30c form 2026

1. Click ‘Get Form’ to open the 30C form in the editor.
2. In the 'INJURED WORKER' section, type or print the injured worker's name, date of birth, and contact information. Check the box if the worker is a minor.
3. In the 'EMPLOYER' section, enter the employer's name and address. Indicate whether the injury occurred on their premises by selecting 'YES' or 'NO'. If 'NO', provide details of where it happened.
4. Fill in the 'INJURY' section with the date of injury, town of occurrence, body parts affected, and a brief description of how the injury happened. Check any applicable boxes for occupational disease or PTSD claims.
5. Sign and date in the 'SIGNATURE OF INJURED WORKER OR REPRESENTATIVE' area. If you are not the injured worker, include your details as well.
6. After completing, make two copies of your form. Send the original to your employer via certified mail or deliver it personally with acknowledgment.

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