Please type or print the employee's claim; provide all information requested.
Injury details: how did this injury or occupational disease occur? Be specific and answer in detail; use additional sheet if necessary.
Occupational disease: when did you first have knowledge of the disability and its relationship to your employment?
Treatment: have you advised the patient to remain off work five days or more?
Work duty: if no, is the injured employee capable of full duty or modified duty?
| Question | Answer |
|---|---|
| Form Name | Form C-4 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 79 |
| Avg. time to fill out | 14 min |
| Edition | Rev 02/25 |
| Treating provider mails | Within 3 working days of treatment |
| Other names | C-4, C4, Form C-4, Form C4, Employee's Claim for Compensation/Report of Initial Treatment |
| Official source | Form C-4 (Rev 02/25), |
Form C 4 isn’t the one you’re looking for?