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REPORT OF INJURY FAX COVER SHEET Complete this form and fax it to 1-800-442-0597 or call 1-800-442-0593 All claims should be reported to MEM within 24 hours. To Missouri Employers Mutual Insurance Attention Customer Service Center From Name of company Name of injured employee Date injury was reported to employer Please indicate what type of injury you are reporting. Revision Date June 2008 OF INJURY EMPLOYER NAME ADDRESS INCL ZIP FORM INJURY REPO.

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