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Is not the employer or carrier for this claim. denies liability for this workers compensation claim. Date of Denial admits liability for this workers compensation claim. If liability admitted do you accept liability for the attached medical expenses Yes No Has either party to this claim requested a hearing before the Industrial Commission Yes No Has a compromise settlement agreement been approved Yes No Date Approved Signature of Check One .

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Keywords relevant to Form 26i

  • Questionnaire
  • provider
  • denies
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