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Get 2015 Ar4 Fillable Form

E Ann. 11-9-810 Revised: 1-1-2011 REPORT OF COMPENSATION PAID/SUSPENSION OF PAYMENTS AMENDED REPORT Closing Report Report of Payment Suspension AWCC File No. Death/PTD Maximum Liability Update Report (additional payments only) Carrier Claim No. Employer Name Employee Name (Last, First, MI) City Employee S.S. Number State Carrier or Self-Insured Name Zip Code Claims Office Location (mailing address) DISABILITY INFORMATION Date of Injury Last Day Employee Worked.

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