104a form 2026

1. Click ‘Get Form’ to open the 104a form in the editor.
2. Begin by filling out your personal information in sections 1-13, including your name, social security number, and date of birth. Ensure all details are accurate.
3. In sections 14-19, provide your employer's information. If known, include the Federal Employer Identification Number (FEIN). Remember, a separate form must be filed for each employer.
4. Complete sections 20-24 with your employment dates and wage information. Specify whether your earnings are hourly or weekly and list any injury dates.
5. In section 25, describe the nature of your disability and how it occurred. Be clear about the relief you are seeking.
6. Answer questions in sections 26-33 regarding other employment and benefits received during your disability period.
7. List healthcare providers in section 35 and witnesses in sections 36 and 37 as required.
8. Finally, certify that all information is true by signing at the bottom of the form before submitting it through our platform.

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