Wsib Form 6 - Worker'S Report Of Injury/disease Page 4

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6
Worker's Report
of Injury/Disease (Form 6)
Claim Number
Please PRINT in black ink
Social Insurance Number
Worker Name - Last Name
First Name
K. Additional Information
The Workplace Safety & Insurance Act requires you to give a copy of this report
0006A (07/05)
Page 4 of 4
(Worker's Report of Injury/Disease - Form 6) to your employer
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