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Case Report by Injured Employee This form must be sent to the Central Office ATTN Matt Hirsch. Employee Demographics Date of Birth Your Home Address Social Security Number Home Phone Job Title Full-time Part-time Volunteer Building Date of Hire Weekly Wage Accident Information Date of Accident Time Work Began Time of Accident In your own words please describe what happened What physical problems do you relate to this injury Did you report this injury to your supervisor Yes No If no why...

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