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Get Md Wcc Uef Claimant Questionnaire. Claimant Questionnaire Version 8/15/07

S the following questions to the Claimant. BE ADVISED THAT THE WORKERS COMPENSATION COMMISSION WILL NOT CONDUCT A HEARING ON YOUR CLAIM UNTIL YOU HAVE COMPLETED AND FILED THIS QUESTIONNAIRE. 1) State your full name, address, telephone number, social security number and date of birth. 2) State the full name, address and telephone number of your employer at the time of your injury. 3a) Were other companies involved in the project or jobsite on which you were injured? If yes, state each com.

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