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Get Petition To Determine Compensation Due - Division Of Industrial Affairs

Carrier Case File No. Employer The undersigned petitioner respectfully represents: That the above named claimant and the above named employer have failed to reach an agreement in regard to compensation due said claimant as an employee of said employer. The undersigned therefore prays that your Honorable Board shall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law and state its conclusion.

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