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2 NOTICE OF RETAINER (PLEASE READ CAREFULLY) OWCP CASE # SS# Name Date of Accident, Illness or Injury Part or Parts of Body Injured Address Claimant Employer Carrier Attorney or Representative A. 1. I have retained the above-named to represent and appear for me in all proceedings concerning my claim under the Longshore and Harbor Workers' Compensation Act, as amended and extended. I authorized the named person/ persons to review the Office of Workers' Compensation Programs file on this in.

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