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Get Po Box 44269 Olympia Wa 98504

Pply: 1) Complete and sign this section of this form. 2) Take form to your employer and vocational counselor to complete. 3) Mail this paperwork to the above address. Questions? Contact your claim manager. Worker s Section At the time of injury, I was working: I am currently working: hours per day hours per day days per week. days per week. My gross earnings, before deductions, for the work period: to were $ On the date o.

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