Injured Worker Information 2025

1. Click ‘Get Form’ to open the Injured Worker Information document in the editor.
2. Begin by entering the Claim Number at the top of the form. This is essential for tracking your appeal.
3. Fill in the Employer Information section, including the employer's name, address, city, state, zip code, telephone, and fax number.
4. Next, provide your information as the Injured Worker. Include your name and contact details in the designated fields.
5. In the Injured Worker’s Representative Information section, if applicable, enter your representative's details including their Rep ID#, name, telephone, and fax.
6. Complete the Reason for Appeal section by clearly stating your reasons. If you intend to file new evidence not available at the last hearing, check 'Yes' or 'No'.
7. Finally, review all entered information for accuracy before signing and submitting your appeal notice.

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