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Get Employers First Report Of Injury Or Illness Nm Form

NT IN INK or TYPE Enter dates in MM/DD/YYYY format. 1. EMPLOYEE SOCIAL SECURITY # DO NOT USE THIS SPACE 2. OSHA Case # 3. DATE OF CLAIMED INJURY 4. Time of injury 5. Time employee began work on date of injury 7. Gender 8. Marital am pm 6. EMPLOYEE Name (last, first, middle) M F Status 10. Home phone # 9. Home Address City State 15. Average weekly wage F R 0 1 Zip Code 16. Rate per hour 12. Occupation 17. Hours per day am pm Married Unmarried 11. Date of birth 13. Regular dep.

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