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Ensation Act, as Extended) Print www.dol.gov/owcp/dlhwc/index.htm Reset Instructions to Employee: You are required to complete and sign this form and return it to the employer/ insurance carrier/ special fund listed in item 4 within 30 days after receipt even if you have no earnings to report. (20 CFR 702.286) See page 2 for definition of "Earnings" and additional instructions. Loss of compensation benefits may result if this form is not completed and filed in accordance with instructions.

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