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Get Print Form Department Of Emergency And Military Affairs State Of Arizona Supervisor's Report Of

-8583 once injury is reported (within 24 hours) Date/Time Called: Initials: **In addition to calling the 800#, this form must be completed by the Supervisor. FAX TO: 602-267-2954 WORKER'S INFORMATION LAST NAME, FIRST NAME, MI SOCIAL SECURITY # EIN # HOME ADDRESS, CITY, ZIP CODE HOME PHONE GENDER EMPLOYEE'S DIVISION/SECTION Male Female DATE OF BIRTH (Day, Month, Year) # OF DEPENDENTS MARITAL STATUS S D M W EMPLOYEE SUPERVISOR'S LAST NAME, FIRST NAME, MI SUPERVISOR'S PHONE # SPVS.

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