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Get Pinnacol Assurance First Report of Injury 2015-2024

_______________________ Safety Equipment Provided Safety Equipment Used RETURN TO WORK INFORMATION Has the Injured Worker Returned to Work? Yes Yes Estimated Return to Work Date: ________ /________ /________ No (Claim is lost time if there is a loss of more than three scheduled work days due to the injury). MEDICAL PROVIDER INFORMATION: Where Was Your Employee Treated? No Medical Treatment Treated by Employer 911 Called Emergency Room Employer Questioning Liability No Date Returned to .

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