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U.S. Department of LaborBenefits Review Board 200 Constitution Ave. NW Washington, DC 202100001BRB No. 170537 MARJORIE BELL SMITH (Mother of TIMOTHY M. BELL, deceased) ClaimantPetitioner v. SERVICE
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How to fill out brb no 11-0537 victor
01
To fill out BRB No 11-0537 Victor, follow these steps:
02
Begin by writing the case number and employee's name at the top of the form.
03
Provide the employee's social security number and date of birth in the designated fields.
04
Indicate the employee's job title and the date they last worked.
05
Fill in the date and time of the injury or illness, as well as the location where it occurred.
06
Describe in detail the injury or illness, including any body parts affected and the circumstances surrounding the incident.
07
If the employee sought medical treatment, specify the provider's name, address, and any further details.
08
Include information about any witnesses to the incident, if applicable.
09
Sign and date the form to certify the accuracy of the provided information.
10
Keep a copy of the completed form for your records.
11
Submit the form to the appropriate recipient as instructed by your organization or legal requirements.
Who needs brb no 11-0537 victor?
01
BRB No 11-0537 Victor is needed by employers or individuals who are involved in a workers' compensation claim or legal proceedings related to an injury or illness that occurred in the maritime industry. This form is specific to the Longshore and Harbor Workers' Compensation Act (LHWCA) and is used to report and document such incidents for claims purposes.
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