Follow the steps to fill out the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name in the designated field. Ensure that you provide your legal name as it appears on identification documents.
3. Fill out your address completely. Include the number and street, city or town, state, and zip code.
4. In the ‘Date of Injury’ field, enter the specific date on which the injury occurred. This is crucial for processing your request.
5. Provide your date of birth in the required field. This information is necessary for identification purposes.
6. Enter the ‘Injured Body Part’ where the injury has occurred. Clearly indicate the affected area to assist in your rehabilitation services.
7. Specify the city or town where the injury took place. This helps the commission in processing your case.
8. List your employer at the time of injury. Providing the correct employer name is essential for your claim.
9. Indicate your preferred services that will assist you in returning to work. This information is vital for tailoring your rehabilitation plan.
10. Sign the form as ‘EMPLOYEE SIGNATURE REQUIRED’ to confirm your request for services. Date your signature accurately.
11. Finally, review all entered information for accuracy. Once confirmed, you can save changes, download, print, or share the completed form.

Complete your documents online to ensure timely processing of your rehabilitation services.