C 11 form 2026

1. Click ‘Get Form’ to open the c 11 form in the editor.
2. Begin by entering the 'Claim Information' section. Fill in the Date of Injury/Illness, WCB Case #, and Claim Administrator Claim #. Ensure all numbers are accurate for proper processing.
3. Next, move to the 'Employee Information' section. Input the employee's Last Name, First Name, Mailing Address, City, State, Zip Code, Daytime Phone #, Country, Email Address, Social Security #, Gender, and Date of Birth.
4. Proceed to the 'Employer Information' section. Enter the Employer Name and their Mailing Address details including City, State, Zip Code and Phone #.
5. In the 'Insurer Information' section, provide Insurer Name and ID along with their Mailing Address and Phone #.
6. Complete the 'Loss of Time' section by detailing Start Date and Return To Work Date along with reasons for loss of time due to injury.
7. Indicate if there was an increase or decrease in hours worked or wages paid. If yes, specify changes in Employment Status including Effective Date and Earnings.
8. Finally, fill out the 'Prepared By' section with your Last Name, First Name, Employer Name, Official Title, Phone #, Email Address and Date of this report before submitting.

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