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Get SAIF X801 2017-2024

Eted by (please print): 29. Date: Employer Complete the rest of this form and give a copy of the form to the worker. Notify SAIF within five days of knowledge of the claim. 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 fro.

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