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Get Workers&#39 Compensation

ID #: Department Name: Date of Accident: Office Location: Time of Accident: Office Phone #: Place of Accident: Employee s Description of Accident (Include Cause of Injury): Part of Body Affected: Injury/Illness that Occurred: Injured Employee s Signature: Supervisor Supervisor s Name: Supervisor s Signature: Agree with Description of Accident? Office Phone #: Yes No Office Location (Bldg # & Room #): Keep a copy in your office, and send original.

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