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Get WCB C-040 2006

E Modified Duties First Name: Address: Initial: Social Insurance #: City: Province: Postal Code: Prov. Health Care #: Home Telephone: Date of Birth: Prov. Y M D Sex: M F Occupation: Employer Information Employer Name or Government Dept.: Employer Account Number: Industry: Address: Does injured worker have personal coverage? Yes No City: Is injured worker a partner or director in this business? Yes No Province: Postal Code: Employer / Supervisor Contact Name: Telep.

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