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R more coronary arteries? (Check one) W.C.B. CASE NO. (if known) CARRIER CASE NO. (if known) First Name CARRIER CODE NO. Middle Initial No DATE OF INJURY SOCIAL SECURITY NO. Apt. No. Address (Give Number and Street, City, State, Zip Code) Last Name 1. VOLUNTEER FIREFIGHTER 2. FIRECOMPANY 3. POLITICAL SUBDIVISION LIABLE FOR BENEFITS 4. (a) Marital Status INFORMATION, REGULAR WORK (b) Sex (c) Date of Birth (e) Tel. No. ( ) 5. Describe in detail your duties in regular employment 6.

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