Form online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the Employer Information section. Fill in your employer's name, control number, and address including ZIP code.
3. Next, move to the Employee Information section. Enter your Social Security Number, name, birthdate, and address. Indicate if your employment has terminated or if you are currently on layoff.
4. In the Claim Information section, specify whether your absence is work-related and provide details about any accidents. Describe the nature of your illness or injury and state your expected return to work date.
5. Complete the Release section by signing and dating it. Ensure that all information is accurate as it will be used for claim evaluation.
6. Finally, review all sections for completeness before submitting the form back to your employer via mail or fax.

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