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Form 25r 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the IC File Number, Employee Code, and Carrier Code at the top of the form. These identifiers are crucial for tracking your claim.
- Fill in the Employer's FEIN and name, followed by the employee’s name and address. Ensure all details are accurate to avoid processing delays.
- In the section regarding the employee's work-related injury, indicate the percentage of impairment for each body part affected. If applicable, describe any amputations on the reverse side.
- Complete the physician's signature section, including their printed name and Federal Tax ID Number. This validates your submission.
- Finally, review all entries for accuracy before submitting. Attach any necessary documents such as audiograms or calculations of hearing loss as required.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2008 | 4.9 Satisfied (42 Votes) |
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