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Carrier s No. city line1 7. Sex Male 1. OWCP No. Telephone No. 17. Has 3rd party or other claim been made because of this Injury 20. 7 Disclosure of the claimant s Social Security Number SSN or tax identifying number TIN on this form is mandatory. 552a you are hereby notified that 1 the Longshore and Harbor Workers Compensation Act as amended and extended 33 U.S.C. To file a claim for compensation benefits complete and sign this form. If you have already been assigned an OWCP Case Number...
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