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Top of the report. Fill out the Date of Injury/Illness, to the best of your knowledge. If you do not have or know the Workers' Compensation Board Case Number or Claim Administrator Claim Number, please leave the corresponding field blank. It is not required to process the form. Insurer / Claim Administrator Information: Insurer Name the name of your Workers Compensation Insurer or Self-Insured Group name. Insurer ID Carrier Code Number (W Number) issued by the Workers' Compens.

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