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Get IA-1 1993

PHONE NO) TO CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN POLICY / SELF-INSURED NUMBER ADMINISTRATOR FEIN AGENT NAME & CODE NUMBER NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED ADDRESS (INCL ZIP) SEX MARITAL STATUS UNMARRIED SINGLE/DIVORCED OCCUPATION/JOB TITLE MALE TELEPHONE (INCLUDE AREA CODE) RATE FEMALE MARRIED UNKNOWN SEPARATED # OF DEPENDENTS DAY MONTH WEEK OTHER: UNKNOWN # DAYS WORKED/WEEK STATE OF HIRE EMPLOYMENT STATUS NCCI .

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