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Form 19 2008-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the IC File # and Employer Code # at the top of the form. These are essential for identifying the injury report.
- Fill in the employer's details, including name, address, and FEIN. Ensure all required fields marked with an asterisk (*) are completed.
- Provide information about the employee, including their name, Social Security Number, date of birth, and contact details.
- Detail the incident by specifying the location, date, time of injury, and nature of business. Include a description of how the injury occurred.
- Complete sections regarding wages and employment duration. This includes average weekly wages and any additional benefits provided.
- Review all entries for accuracy before submitting. Once finalized, transmit the form through your insurance carrier as required by law.
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