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EMPLOYEE ACCIDENT REPORT TO BE COMPLETED BY INJURED EMPLOYEE Name: Date of Injury: Owner/Operator Name: City of Injury: / / Store No: TO BE COMPLETED BY INJURED EMPLOYEE 1. Home Address: Apt #: City:
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Submit this report to the appropriate regulatory body or authority.
All individuals or entities specified by the regulatory body are required to file and submit this report.
You can fill out and submit this report online through the regulatory body's designated portal or by mailing a physical copy.
The purpose of submitting this report is to provide necessary information to the regulatory body for monitoring and compliance purposes.
The report must include specific financial, operational, or other relevant information as required by the regulatory body.
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