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Get AZ ICA 04-0101 2001-2024

ER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS EMPLOYEE’ S WAGE DATA IMPORTANT 36. WAS WORKER IN YOUR EMPLOY WHEN INJURED? YES NO o 37. HOURS PER DAY EMPLOYEE WORKED o FROM IF WORK LOSS IS EXPECTED TO EXCEED SEVEN CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47 43. NUMBER OF MONTHS EMPLOYMENT AVAILABLE DURING THE YEAR A.M. P.M. THRU 40. DATE OF LAST HIRE 44. GIVE EMPLOYEE’ WAGE STATUS AS APPLICABLE S HOUR DAY WEEK MONTH o o o $ PER 46. ACTUAL GROSS EARNINGS OF .

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