30c form 2026

1. Click ‘Get Form’ to open the 30C form in the editor.
2. In the 'INJURED WORKER' section, type or neatly print the name of the injured worker, their date of birth, and check if they are a minor. Fill in their address and telephone number.
3. In the 'EMPLOYER' section, enter the employer's name and address. Indicate whether the injury occurred on their premises by selecting YES or NO.
4. In the 'INJURY' section, provide the date of injury, town of occurrence, body parts affected, and a brief description of how the injury happened. Check if it’s an occupational disease or repetitive trauma.
5. Sign in the 'SIGNATURE OF INJURED WORKER OR REPRESENTATIVE' box and include your contact information if you are not the injured worker.
6. After completing, make two copies of your form. Send the original to your employer via certified mail or deliver it personally with acknowledgment.

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