self insurance form

Description
Department of Labor and Industries Self Insurance Section PO Box 44892 Olympia WA 98504-4892 Self Insurance Vocational Reporting Form Account Injured Workers Name VRC Provider ID: City State Zip VRC Phone Number: ( ) Voc Firm Number: Employer VRC Name: VRC Address: Vocational Firm Name: Injured Worker's Address: Legal Representative's Name: Attending Physician's Name: City Claim Number VRC Provider Number: Voc...
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self insurance form
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