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Employees: Billing contact: Phone: Ext: Fax: Phone: Ext: Fax: Fax: Email: City: State: Fax: Email: City: State: CEO: After hours contact: Drug screening contact name: Department: Phone: Different billing address? List here: Address (line 2): Zip: Work comp contact name: Department: Phone: Different billing address? List here: Address (line 2): Who would you like called for workers compensation authorizations (check one)? Zip: Insurance Carrier Company When wo.

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