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OF BENEFITS INITIAL PAYMENT Board Claim No. RE-COMMENCE SUSPEND Employee Last Name WC-1 Dated WC-2 Dated AMENDMENT: Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE Employee E-mail EMPLOYER Address Name Address City City State INSURER/ SELF-INSURER CLAIMS OFFICE Insurer/Self-Insurer File # Zip Code State Zip Code Employer E-mail Name Address Name City State Claims Office E-mail Phone Number Zip Code SBWC ID# (five.

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