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Get National Employee Leasing Form NC2745 - NCCI Holdings, Inc.

FOR THE CURRENT PERIOD 1. Effective Date 2. Policy No. 3. Carrier Experience Rating Plan Manual 2003 Edition 2002 National Council on Compensation Insurance Inc. NC2745 FORM WORKERS COMPENSATION EXPERIENCE RATING FOR FORMER CLIENTS OF LABOR CONTRACTORS 4. State Class Code Payroll Claim No. Accident Date Injury Type Open/ Closed Indemnity Medical Actual Incurred Losses Loss Cov. Cat. No. A7 NC2745 Page 1 of 2 APPENDIX Oct 2003 1 Please follow the .

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