Form 22 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. Indicate the Date of Injury and Date of Birth accurately. These dates are essential for processing claims under the Workers' Compensation Act.
5. 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.
6. If applicable, note any changes in job or pay rate during the reporting period. This ensures transparency and accuracy in earnings documentation.
7. Finally, complete the certification section with an authorized signature and date before submitting your form electronically through our platform.

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