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Ame 0 SUSPEND Employee First Name M.I. Social Security Number Date of Injury A. IDENTIFYING INFORMATION Name of Claimant / Guardian EMPLOYEE Address City INSURER / SELF-INSURER State Name Zip Code Name EMPLOYER Name Address Phone Number CLAIMS OFFICE Address Phone Number Insurer/Self-Insurer File # City State Zip Code SBWC ID # (five digit number) City Claims E-mail State Zip Code Employer E-mail B. DEATH BENEFITS 1. Benefits will be paid at the rate of $ Payable fr.
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