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Get NC Form 28U 2016

IN The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act ( Employee’s Name Employer's Name Address Employer’s Address City ( State ) ( Home Telephone / Sex Telephone Number City State Zip City State Zip Insurance Carrier Zip ) Work Telephone M F Social Security Number ) Carrier's Address ( / Date of Birth ) ( Carrier's Telephone Number ) Fax Number SECTION A. EMPLOYEE: COMPLETE AND MAIL TO EMPLOYER AND CARRIER/ADMINISTRATOR.

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