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This document outlines the decision regarding Richard A. Samalonis' claim for workers' compensation benefits related to a bilateral carpal tunnel condition. It details the findings of the Employees’
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How to fill out 01-1626doc - dol:
01
Provide your personal information, including your name, address, and social security number, in the designated fields.
02
Indicate the type of claim you are filing by checking the appropriate box. Options may include workers' compensation, disability, or family and medical leave.
03
Fill in the details of your claim, including the dates of the incident or onset of the illness, the nature of the injury or condition, and any medical treatment you have received.
04
Provide information about your employment history, including the dates of your employment, the name and address of your employer, and your job title.
05
Attach any supporting documents, such as medical records, accident reports, or witness statements, that may help substantiate your claim.
06
Sign and date the form to certify the accuracy of the information provided.
Who needs 01-1626doc - dol?
01
Employees who have experienced a work-related injury or illness and need to file for workers' compensation benefits.
02
Individuals seeking disability benefits due to a medical condition that prevents them from working.
03
Employees requesting family and medical leave due to the birth or adoption of a child, their own serious health condition, or to care for a family member with a serious health condition.
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01-1626doc - dol is a document used by the Department of Labor (DOL) to collect information regarding labor union financial activities.
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