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28c 2026
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- Click ‘Get Form’ to open the 28c in the editor.
- Begin by entering the Employee’s Name and Employer's Name in the designated fields. Ensure accuracy as this information is crucial for processing.
- Fill in the addresses for both the employee and employer, including city, state, and zip code. This helps in identifying the parties involved.
- Provide contact numbers, including home and work telephone numbers. This ensures that all parties can be reached if necessary.
- Complete the sections regarding accident details, including date of accident or disability and whether salary was continued during this period.
- Input the number of weeks for temporary total, partial, and permanent partial benefits along with their corresponding dollar amounts.
- Fill out disfigurement amounts and loss of organ or body part benefits paid. Sum these amounts in the total section.
- Finally, review all entries for accuracy before signing at the bottom of the form. Ensure you include your title and date.
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