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Get WORKERS COMPENSATION EMPLOYER'S FIRST REPORT OF ...

ADMINISTRATOR CLAIM NUMBER JURISDICTION REPORT PURPOSE CODE JURISDICTION CLAIM NUMBER INSURED REPORT NUMBER LOCATION # EMPLOYER S LOCATION ADDRESS (IF DIFFERENT) PHONE # SIC CODE EMPLOYER FEIN CARRIER (NAME, ADDRESS & PHONE NO) POLICY PERIOD Workers Compensation Fund of Utah P.O. Box 57929 Salt Lake City, UT 84157-0929 Telephone: (801) 288-8010 TO CHECK IF APPROPRIATE CARRIER FEIN CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO.) SELF INSURANCE POLICY/SELF INSURED NUMBER ADMINISTRATO.

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