Workers Compensation Employees Notice Of Injury Page 2

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ADDITIONAL DETAILS HOW INJURY OCCURRED
PREVIOUS INJURIES OR ILLNESSES
DATE(S) OF
WAS THIS
IF YES,
INJURY /
WORKERS’
AMOUNT OF
ILLNESS
DESCRIBE INJURY / ILLNESS
COMPENSATION
NAME AND ADDRESS OF DOCTOR
SETTLEMENT
YES OR NO
ADDITIONAL DETAILS CONCERNING THIRD PARTY NEGLIGENCE

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