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Click ‘Get Form’ to open the 9p 10 workers document in the editor.
Begin by entering your personal information in the 'Claimant' section, including your name, address, and Social Security number.
Fill in the 'Date of Injury' and 'Nature of Injury or Illness' fields accurately to ensure proper documentation.
Provide details about your employer and insurance carrier in the designated sections to clarify responsibility for medical costs.
Review the notice carefully. It outlines potential financial responsibilities if your claim is not prosecuted successfully.
Sign and date the form at the bottom to acknowledge your understanding of these responsibilities before submitting it.

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2012	4.9 Satisfied (281 Votes)

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