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Get GA WC-102b 2007

NT OR EMPLOYEE BY AN ATTORNEY Board Claim No. Employee Last Name Employee First Name M.I. Social Security Number Date of Injury A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE Employee E-mail City ATTORNEY FOR EMPLOYEE / CLAIMANT State State Name Zip Code Zip Code Name EMPLOYER Address Address City State Zip Code City GA Bar number Employer E-mail Attorney E-mail INSURER / SELF-INSURER Name PARTY AT INTEREST Name Name CLAIMS OFFICE Address Address C.

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