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1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section A, which requires Worker Information. Enter the worker's full name, job title, and address. Ensure you check if the worker is an executive or a relative of the employer.
3. Proceed to Section B for Employer Information. Provide your firm's legal name, account number, and contact details. Indicate if your firm has 20 or more workers.
4. In Section C, detail the Accident/Illness Dates and Details. Fill in the date and time of the incident, who it was reported to, and select the type of accident from the provided options.
5. Complete Sections D through J as applicable based on whether there was lost time or modified work. Be thorough in describing any health care received and wage information.
6. Finally, review all sections for accuracy before submitting your form electronically through our platform.

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