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Get Vwc Form 45a

Surer Period covered From Address Insurer code / / Insurer location Contact Person To / / . Date filed Phone number Payments NOTE: If this accident has been previously reported on Form 45A, pl ace an X in the box by the entry. Name of employee Social Security Number Address of employee Date of accident Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name.

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