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Get AL WC Form 3 2012-2024

LAW SUPPLEMENTARY REPORT Please type or print The original of this form must be filed with this office. Copies will not be accepted. FIRST PAYMENT REINSTATEMENT AMENDED 1. Employee: 2. Social Security number: 3. Employer: 4. Unemployment Compensation Number: 5. Date of Injury: 6. Date disability began this period: 7. Insurance carrier: 8. Claim # Service Co # 9. Name, address and telephone number of office filing this report: Phone: Ext: A. 10. On was paid for the period from th.

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