C504: Fill out & sign online

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Click ‘Get Form’ to open the c504 in the editor.
Begin by entering your Claim Number and Worker’s Name, including surname, first name, and initial. Ensure accuracy for proper identification.
Indicate whether you will be off work due to the injury by selecting 'Yes' or 'No'.
Fill in your Personal Health Number and Date of Birth in the specified format (Year/Month/Day).
Answer the questions regarding your job title and describe a typical workday. Be specific about any changes that may have contributed to your symptoms.
Check all applicable symptoms from the list provided, such as pain or numbness, and specify when these symptoms were first noticed.
Detail tasks performed at work that may cause or increase symptoms, including how often you perform these tasks each day.
List any medical treatments received for this condition along with your doctor's information.
Complete any additional sections regarding past injuries, medications, and activities affected by your injury.

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