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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.
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All individuals or entities specified by the regulatory body are required to file and submit this report.
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The purpose of submitting this report is to provide necessary information to the regulatory body for monitoring and compliance purposes.
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The report must include specific financial, operational, or other relevant information as required by the regulatory body.
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