C64 form 2025

1. Click ‘Get Form’ to open the c64 form in the editor.
2. Begin by entering the WCB Case Number and Carrier Case Number if known. This information helps identify the case.
3. Fill in the Date of Accident or Injury and Time, along with the Address Where Accident or Injury Occurred. Accurate details are crucial for processing.
4. Provide the Deceased Person's Name, Address, Date of Birth, and Social Security Number. Ensure all personal information is correct.
5. Complete sections for Employer and Insurance Carrier details. If applicable, indicate if the claim is related to a Volunteer Firefighter or Ambulance Worker.
6. Document the Date and Place of Death, as well as the Decedent's marital status at time of death.
7. Answer questions regarding your relationship to the deceased and your medical history with them, including dates of visits.
8. Describe how the accident occurred and provide a detailed account of injuries sustained. This section is vital for understanding causation.
9. State the direct cause of death and any contributory causes. Confirm whether a coroner's inquest was held.
10. Finally, ensure you sign as the attending physician, providing your W.C.B. Rating Code and Authorization Number before submitting.

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