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Get AIG WC9552b 2016-2024

M Worker To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer. If you do not intend to file a workers' compensation claim with the insurance company, do not sign the signature line. Your employer will give you a copy. Date of Date you Time you began work a.m. Regularly scheduled DEPT USE: Emp injury or illness: left work: on day of injury: p.m. days off: a.m. a.m. Time of injury Time you Check here if you have more than one.

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