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W WORKERS C COMPENSATION A APPLICATION Edgewood Partners Insurance Center Phone: (866) 923-3742 Fax: (866) 924-3742 PLEASE ATTACH CURRENTLY VALUED LOSS RUNS FOR 2009 THROUGH CURRENT A APPLICANT INFORMATION

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What is workers39 compensation application?

Workers' compensation application is a form that is filled out by an employee who has suffered a work-related injury or illness in order to claim compensation benefits from their employer's insurance policy.

Who is required to file workers39 compensation application?

Any employee who has suffered a work-related injury or illness is required to file a workers' compensation application.

How to fill out workers39 compensation application?

To fill out a workers' compensation application, the employee needs to provide their personal information, details of the injury or illness, information about the employer, and any medical documentation related to the incident.

What is the purpose of workers39 compensation application?

The purpose of a workers' compensation application is to allow employees who have suffered work-related injuries or illnesses to claim medical treatment, wage replacement, and other benefits provided by the workers' compensation insurance.

What information must be reported on workers39 compensation application?

The workers' compensation application must include the employee's personal information (name, address, contact details), details of the injury or illness (date, description, body parts affected), employer information, and any supporting medical documentation.

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