Form 113 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the EMPLOYEE section. Fill in your name, street address, city, state, zip code, date of birth, telephone number, and social security number.
3. Next, provide details about your employer at the time of injury or last exposure. Include the employer's name, street address, city, state, and zip code.
4. In the NATURE OF INJURY OR OCCUPATIONAL DISEASE section, describe your injury or disease clearly. Then enter the DATE OF INJURY OR LAST EXPOSURE.
5. Identify your FIRST DESIGNATED PHYSICIAN by filling in their name and contact details including street address, city, state, zip code, and telephone number.
6. Review the MEDICAL INFORMATION RELEASE statement and ensure you understand its implications before signing and dating it.
7. Finally, complete the MEDICAL PAYMENT OBLIGOR section with their name, representative's name (if applicable), street address, city, state, zip code, and telephone number.

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