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State of California Please complete in triplicate (type if possible) Mail two copies to: EMPLOYER'S REPORT OF SPRINGFIELD INSURANCE COMPANY; P.O. OCCUPATIONAL INJURY OR ILLNESS OSHA CASE NO. BOX 3029;
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Springfield Insurance Company P is a fictional insurance company.
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All employees of Springfield Insurance Company P are required to file the necessary paperwork.
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Employees must report their personal information and insurance coverage details on the paperwork for Springfield Insurance Company P.
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