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Get Form Db 681 2012

OFFICE WORKERS COMPENSATION BOARD SELF-INSURANCE OFFICE 328 STATE STREET, 3RD FLOOR SCHENECTADY, NY 12305 FROM: (Name and Address of Self-Insured Employer) Carrier ID No. (Required) B ALL CLAIMS AND COVERAGE (Including Pregnancy Related Disabilities) 1. BENEFITS AND CLAIMS (TOTAL) STATUTORY COV. PLAN COVERAGE TOTAL a. Number of initial indemnity claims allowed 0 b. Number of weeks for which indemnity benefits were paid 0 c. Amount of indemnity paid $ d. Amount of Hospital, Surgi.

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