Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the employee information section. Enter the employee's full name, date of birth, social security number, and other required personal details. Ensure that you include the occupation/job title and marital status. Indicate whether the employee is male, female, or if the sex is unknown.
3. Next, provide the employee’s contact information including their address, telephone number, and their employment details such as date hired, hours worked per day, and average weekly wage.
4. In the employer information section, fill in the employer's name, identification number, SIC code, and complete address. Make sure to include the insurance carrier information if applicable.
5. Proceed to the occurrence/treatment information section. Enter the date and time of the injury/exposure, and provide details about the event, including the location, type of injury, and how the injury occurred. Include any relevant medical treatment details if applicable.
6. Finally, review the form to ensure all information is accurate. You can save your changes, download a copy, print the form for your records, or share it as required.

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