This form is used by the insurance company to request information from the injured employee. The employee must report to the insurer all earnings, including wages or salary from self-employment for the 26 weeks indicated on the form.

This form is sent just to the insurer. A copy is not sent to the DIA. If you have any questions regarding this form, please contact the workers' compensation insurance carrier!

Print Form 126  pdf format of Form 126

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