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Get Co Wc164 2014-2024

ED WORKER AND THE INSURER. Initial 2. CASE INFORMATION 1. REPORT TYPE Progress Closing Date of Injury Injured Worker Social Security # Date of Birth 3. EXAM DATE Insurer Claim # Insurer Name/TPA Insurer Phone/Fax Employer Name INITIAL VISIT (only) a. Injured worker s description of accident/injury Yes b. Are your objective findings consistent with history and/or work-related mechanism of injury/illness? 5. Working Not Working.

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