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Get NY WCB C-3 2009

Y. This form may also be filled out on-line at www.wcb.state.ny.us. WCB Case Number (if you know it): A. YOUR INFORMATION (Employee) 2. Date of Birth: ______/______/______ 1. Name: First MI Last 3. Mailing address: Number and Street/PO Box - 4. Social Security Number: 7. Do you speak English? City - Yes State Zip Code 5. Phone Number: (_____)_______________ 6. Gender: Male Female No If no, what language do you speak? B. YOUR EMPLOYER(S) 1. Employer when injured: 2. Phone Number.

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