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MAIL TO: WORKERS COMPENSATION INSUREREmployee Social Security Number Employer UI Account NumberEMPLOYER REPORT Employer Federal ID Number OF INJURY/ILLNESS This report is completed by the Employer
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What is this report is completed?
This report is completed when all required information has been accurately filled out.
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The individuals or entities specified in the regulations are required to file this report.
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The information required on this report includes personal and financial details as specified by the regulations.
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