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Get SAIF X801 2011

Even if the worker does not wish to file a claim, maintain a copy of this form. 30. Employer legal business name: 31. Phone: 32. FEIN: 33. If worker leasing company, list client business name: 34. Client FEIN: 35. Address of principal place of business (not P.O. Box): 36. Insurance policy no.: 37. Street address from which worker is/was supervised: 38. Nature of business in which worker is/was supervised: ZIP: 39. Address where event occurred: 40. Was injury caused by failure.

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