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MUST BE TYPED OR PRINTED IN BLACK INK. Board Claim No. Employee Last Name Employee First Name M. I. Date of Injury SSN or Board Tracking A. IDENTIFYING INFORMATION Male Female EMPLOYEE Birthdate Phone Number Employee E-mail Address City Name State NAICS Code Nature of Business Trade Transport Mfg. etc. Zip Code Insurer/Self-Insurer FEIN CLAIMS OFFICE Employer FEIN INSURER / SELF-INSURER Claims Office FEIN SBWC ID five digit no. EMPLOYER S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE WC-1...
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