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). SORM CLAIM # EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS 1. Name (Last, First, M.I.) 2. Sex M - 3. Social Security Number 4. Home Phone ( 6. Does the Employee Speak English? YES 5. Date of Birth (m-d-y) ) 17. Date Lost Time Began (m-d-y) - 16. Time of Injury 15. Date of Injury (m-d-y) F - : - 18. Nature of Injury* am pm 19. Part of Body Injured or Exposed* - If No, Specify Language 20. How and Why Accident/Injury Occurred* NO 7. Employee Telephone # 9. Mailing Addres.

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