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Get NY SI-4.1 2009-2024

OF INJURED (Last Name, First Initial) Date of Accident Weekly Comp. Rate PLEASE TYPE Describe injury and any complications. Give latest medical status, including return to work dates and degree of permanency estimated. Report Valued as of:______________________________________________________ No. of Weeks of Disability Paid to Date Year of Birth Has Claimant Returned to Work (Y/N) & Date *Reserve for Future Payments Comp. Medical For Board Use Only Comp. Medical COMPENSATION AND M.

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