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Form 22 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Employee’s Name, Employer's Name, and their respective addresses in the designated fields. Ensure accuracy as this information is crucial for identification.
- Fill in the contact details including telephone numbers and the last four digits of the employee's SSN. This helps in maintaining proper communication regarding the claim.
- Indicate the Date of Injury and Date of Birth accurately. These dates are essential for processing claims under the Workers' Compensation Act.
- In the earnings section, record the amount earned by the employee for each month. Use an X to mark days paid in full, including any paid vacation or sick leave.
- If applicable, note any changes in job or pay rate during the reporting period. This ensures transparency and accuracy in earnings documentation.
- Finally, complete the certification section with an authorized signature and date before submitting your form electronically through our platform.
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