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Ress City State Zip Telephone INSTRUCTIONS When 25 or more employees separate on the same day for the same reason, complete this form, in detail, and the Mass Separation-List of Workers form (DOL-402A). A separate list should be completed for each set of employees for each different reason for separation as shown below. Fax or mail this form and the List of Workers form to the above address/number within 24 hours after the date of separation. This will ensure that claims are handled e.

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