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Get The Above-named Employee Claims Additional Medical Compensation As A Result Of An Injury By

Of This Form Is Required Under the Provisions of the Workers' Compensation Act . ( Employee s Name Employer's Name Address Employer s Address City ( State ) ( Home Telephone Last 4 Digits of SSN Sex Telephone Number City State Zip City State Zip Insurance Carrier ) Work Telephone M F XXX-XX- Zip ) / / Date of Birth Carrier's Address ( ) ( ) Carrier's Telephone Number Fax Number SECTION A. TO BE COMPLETED BY EMPLOYEE: 1. 2. The above-named employee.

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