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Me of police station) No H. Telephone No. Direct settlement (to be completed only where the occupational disease results in temporary incapacity for not more than 7 days and no permanent incapacity, and the employer and employee have chosen to directly settle the employees compensation claim) Period of sick leave Amount of compensation: $ from / / Day / Month / Year to / / Day / Month / Year to / / Day / Month / Year paid to be paid on / / Day / Month / Year Total number of sic.

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