28c 2026

1. Click ‘Get Form’ to open the 28c in the editor.
2. Begin by entering the Employee’s Name and Employer's Name in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Fill in the addresses for both the employee and employer, including city, state, and zip code. This helps in identifying the parties involved.
4. Provide contact numbers, including home and work telephone numbers. This ensures that all parties can be reached if necessary.
5. Complete the sections regarding accident details, including date of accident or disability and whether salary was continued during this period.
6. Input the number of weeks for temporary total, partial, and permanent partial benefits along with their corresponding dollar amounts.
7. Fill out disfigurement amounts and loss of organ or body part benefits paid. Sum these amounts in the total section.
8. 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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