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Print Form LOSS OF TIME STATEMENT OF CLAIM ACCIDENT OR SICKNESS RETURN THIS COMPLETED FORM TO: WESTERN PENNSYLVANIA TEAMSTERS AND EMPLOYER WELFARE FUND 215 South Euclid Avenue; Pittsburgh, PA 152063691
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Return this completed form is a document that must be submitted to the designated authority.
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The purpose of return this completed form is to report specific information as required by the authority.
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