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Name: Employer's Name: Address: Address: City: State: Home Phone: Zip: City: Work Phone: State: Zip: Carrier: Preparer s Phone #: Preparer's Name: A claim for workers compensation benefits is made based on the following grounds: Injury Illness Repetitive Trauma 1. Compensation Rate: 2. AWW: $ Date of Injury: 3. Type of injury and body part(s): 4. Facts in controversy: 5. Legal issues involved: 6. Unusual aspects: 7. Witnesses (designate if expert):* 8. Exhibi.

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