Form 28c 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the IC File Number, Employer Code, Carrier Code, and Carrier File Number at the top of the form.
3. Fill in the Employer FEIN and ensure you only use this form for settled cases.
4. Provide the Employee’s Name, Employer's Name, and both addresses including City, State, and Zip code.
5. Complete the contact information fields such as Home Telephone, Work Telephone, Sex, Social Security Number, and Date of Birth.
6. Detail the accident or disability date and indicate whether salary was continued. Fill in temporary total weeks and amounts as applicable.
7. Continue filling out sections for temporary partial weeks, permanent partial weeks, disfigurement amounts paid, loss of organ benefits paid, and total medical paid.
8. Finally, review all entries for accuracy before signing with your name, title, and date at the bottom of the form.

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