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Get GA WC-20a 2011-2021

M No. Employee Last Name Address Employee First Name M.I. City State SSN or Board Tracking # Zip Code Date of Injury Phone Number EMPLOYEE Name Address EMPLOYER Phone Number INSURER / SELF-INSURER City Name State Zip Code State Zip Code Address Name Phone Number City CLAIMS OFFICE 1. Date disability began 2. Date of first treatment 3. Services authorized by Employer 4. Patient History Dr. (name): Other (specify): 5. Findings from Examination 6. Describe Diagnosis .

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