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Get Georgia Workers' Compensation Exemption Form

O SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY. MUST BE TYPED OR PRINTED IN BLACK INK. Employee Last Name Board Claim No. A. Employee First Name M.I. SSN or Board Tracking # Date of Injury IDENTIFYING INFORMATION Birthdate Male Female EMPLOYEE Phone Number Employee E-mail Address EMPLOYER City Name State NAICS Code Address Nature of Business (Trade, Transport, Mfg., etc.) Phone Number City State Zip Code CLAIMS OFFICE Employer FEIN Employer E-mail Nam.

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