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Get SAIF X801 2010

Of Job Injury or Illness EMPLOYER’S ACCOUNT NO. Workers’ compensation claim Worker To make a claim for a work-related injury or illness, fill out the worker portion of this form and give to your employer. If you do not intend to file a workers’ compensation claim with SAIF Corporation, do not sign the signature line. Your employer will give you a copy. 1. Date of injury or illness: 2. Date you left work: 5. Time of injury or illness: a.m. p.m. a.m. p.m. 6. Time you left work: a.m.

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