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Get Employer's Report Of Work-related Injury/illness

Ployees has a work-related injury or illness, you must complete and file this form within 10 days of the injury/illness or be subject to a penalty. For additional information on filing this form please refer to Workers' Compensation Law Section 110 at the end of this form. Type or print neatly. WCB Case Number (if you know it): Date of Injury/illness: / / Carrier Case Number (if you know it): Date of this Report: / / A. EMPLOYER INFORMATION 1. E.

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