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Y Hotline 1-800-243-3331 www.WorkforceSafety.com SFN 2828 (07/2014) PLEASE PRINT OR TYPE USING BLACK OR BLUE INK AND RETURN TO WSI. Please see reverse side for Fraud Warning and other information. SECTION 1 Completion of this section is required Claim Number Worker s Mailing Address City State nd Body Part Injured (Example: Left 2 /middle finger, right shoulder, left ankle.) AM PM Sex Marital Status F Single Married M Worker's Home/Cell Phone Number Zip What was the nature of the injur.

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