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TLY COMPLETED FORMS WILL BE RETURNED TO REQUESTOR WITHOUT ACTION. This form must be signed by a party eligible to receive the information requested. Additional documentation may be required for eligibility. The signature must be notarized. (Please type or print) I. CLAIM FILE IDENTIFICATION. Provide the following information to identify the requested claim file. DWC or IAB Number Employee's Social Security Number Employee s Name Employee's Date of Injury -- -- -Last First MI Addres.

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