Form 101 pdf 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the employee's name in the designated field. Ensure you include the last name, first name, and middle initial for clarity.
3. Fill in the home telephone number and address accurately. This information is crucial for communication regarding the injury report.
4. Provide the employee's Social Security Number and select their sex from the options provided. Remember that disclosing this number is voluntary but aids processing.
5. Complete sections on marital status, number of dependents, date of hire, and date of birth. These details help establish context for the injury report.
6. Input average weekly wage and employer details including name, address, and contact number. This information is essential for insurance purposes.
7. Document specifics about the injury such as date, location, source, and a brief description of how it occurred. Be thorough to avoid any misunderstandings.
8. Finally, ensure that all required signatures are obtained before submitting the form to avoid penalties. Review all entries for accuracy before finalizing.

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