Disability 2004 form-2025

1. Click ‘Get Form’ to open the disability 2004 form in the editor.
2. Begin with Part A - Claimant's Statement. Fill in your name, address, and contact information accurately. Ensure that all details are correct as this information is crucial for processing your claim.
3. In section 6, describe your disability clearly. If it’s an injury, include how, when, and where it occurred. This helps establish the context of your claim.
4. Complete section 7 by indicating the date you became disabled and whether you worked on that day. If applicable, provide dates for any subsequent work.
5. List your last employer in section 8 along with their business address and employment dates. This information is vital for verifying your employment history.
6. In section 10, disclose any other benefits you are receiving related to your disability. This includes workers' compensation or unemployment insurance.
7. Finally, review all entries for accuracy before signing and dating the form in section 12. If someone else is signing on your behalf, ensure their details are included.

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