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Get OR Form 827 2015-2024

E/time of original injury: Occupation: Dept. Use Ins. no. Last date worked: Part Phone: Employer at time of original injury — name and street address: Health insurance company name and phone: Event Workers’ compensation insurer’s name, address: Source Assoc. object Phone: Worker: Check reason for filing this form, answer questions (if any), and sign below. First report of injury or disease (Do not complete or sign if you do not intend to make a claim.) Have you injured the same .

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