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Click ‘Get Form’ to open it in the editor.
Begin by entering the Board Claim Number, followed by the employee's last name, first name, and middle initial. Fill in the address details including city, state, and zip code.
Next, provide the employee's Social Security Number and phone number. Then, indicate the date of injury.
For the employer section, input the employer's name, address, phone number, city, state, and zip code.
In the insurer/self-insurer section, fill out similar details as above for the insurer.
Proceed to complete sections regarding disability dates, treatment history, examination findings, diagnosis (including ICD-9 code), treatment description, prognosis, and recovery dates.
Finally, ensure all required signatures are included before saving your completed form for submission.

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Versions	Form popularity	Fillable & printable
2011	4.8 Satisfied (100 Votes)
2007	4.2 Satisfied (70 Votes)

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