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Provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Employer Identification No. Insurer No. EMPLOYER S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE Employee Name and Address: Employer Nam.

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