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Get Ga Wc-20a 2007

Board Claim No. Employee Last Name Address Employee First Name M.I. City State Social Security Number Zip Code Date of Injury Phone Number EMPLOYEE Name Address EMPLOYER Phone Number INSURER / SELF-INSURER City Name State Zip Code State Zip Code Address Name Phone Number City CLAIMS OFFICE 1. Date disability began 2. Date of first treatment 3. Services authorized by 0 Employer 0 Dr. (name): 0 Other (specify): 4. Patient History 5. Findings from Examination 6. .

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