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ATIENT It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. 1. Name of Injured Person: SSN: Age: 2. Address: City: 3. Employer Name: Address: City: 4. Date of Accident: Hour: AM/PM 5. State in patient s own words where and how accident occurred: Sex: State: Zip: State: Zip: Date of Disability: DISABILITY.

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  • hospitalized
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