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Fillable Form 113

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Form 113 Designation of Physician Revised 03-12-03 Two-Sided Form COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS' CLAIMS 657 TO BE ANNOUNCED AVENUE FRANKFORT, KY 40601 Claim No. NOTICE OF DESIGNATED PHYSICIAN EMPLOYEE: Name Street Address ( City, State, Zip Date of Birth Social Security Number ) Telephone Number EMPLOYER AT TIME OF INJURY OR LAST EXPOSURE: Name Street Address City, State, Zip NATURE OF...
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