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Click ‘Get Form’ to open it in the editor.
Begin by entering the WID number or SSN and the date of injury in MM/DD/YYYY format. If applicable, include the date of death.
Fill in the employee's name, employer details, and insurer information. Ensure all fields are completed accurately.
Provide the insurer claim number and dates related to lost time, including when the employer was notified and initial return to work.
Indicate the average weekly wage at the time of injury and check any relevant boxes regarding wage loss benefits.
If there’s a new period of lost time, complete that section with corresponding dates and notifications.
For claims accepted or denied, clearly state reasons and provide necessary details as required in each section.
Finally, ensure that you print your name, phone number, and date served before saving or submitting your form.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (221 Votes)
2010	4 Satisfied (31 Votes)

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