Get Report Of Extended Disability - Nh.gov - Nh

This guide provides clear and supportive instructions on how to complete the Report Of Extended Disability form online. Designed for users with varying levels of experience, this guide will help you navigate each section of the form with ease.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in an online editor.
2. Begin by filling in the claimant's details, including their first name, middle initial, last name, and social security number. Ensure that you enter accurate information as this is essential for processing.
3. Provide the claimant's address including the street number, street name or P.O. Box, city or town, state, and zip code. Ensure this information is complete and up to date.
4. Enter the claimant's telephone number, making sure to include the area code.
5. Select the gender of the claimant by checking the appropriate box. Use the checkmark symbol for either 'Male' or 'Female'.
6. Indicate the highest level of education completed by the claimant by circling the correct number corresponding to their education level.
7. Enter the claimant's age and indicate the dates of injury and disability. Be sure to complete this information in the provided fields using the month, day, and year format.
8. Describe the nature and location of the injury in the designated field. Be specific and detailed to ensure clarity upon review.
9. Provide the name and address of the employer, including their telephone number and employer identification number. This information is relevant for the processing of the claim.
10. Input the carrier name and the carrier number, along with their address if applicable to the claim process.
11. Document the date the employer was contacted regarding the claimant's return to work, and note the employer’s response.
12. Ensure that the signature of the carrier representative is included at the bottom of the form for validation.
13. Once all fields are filled out, review the form for accuracy, then save your changes. You can download, print, or share the completed form as required.

Get started on completing your Report Of Extended Disability online today!