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Get Canada Wsib 1824a 2008

M Nos. For this form to be valid, it must be completed in full by the Representative (Parts A and B) and signed by the worker or employer (Part D) as applicable. Worker Name When submitting by fax, please transmit using only an original form. Worker Date of Birth (dd/mm/yy) Part A - Worker or Employer Directing Authorization Name Worker Employer Address Telephone Employer/Company Name City/Town Fax Postal Code Language English French Other (please specify) Part B - Representativ.

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