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Get Workers Comp Form 100

E certified as vocationally handicapped? Yes 52. Date employer notified by employee V. PREPARER DATA No Yes 48. Value of discontinued fringes No 53. If temporary service agency, provide name/address of employer where injury occurred. I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits. 54. Preparer's name (Pl.

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