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I8. I f1//HARBORGUARD WORKERS COMPENSATION SUPPLEMENTALName of Applicant: Federal Employers ID Number: ___ CCI Risk ID Number: ___ Effective Date: ___ Expiration Date: ___ Workers Compensation Limits:
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Begin by carefully reading the instructions provided on the workers-compensation-application-pg1jpg form.
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Gather all necessary information and documents required to complete the application.
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Fill out your personal details, including your name, contact information, and social security number.
04
Provide accurate and detailed information about your employment history, including the name of your employers, dates of employment, and job titles.
05
Answer any additional questions related to your medical condition or injury that is relevant to the workers' compensation claim.
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Review the completed application form to ensure all information is accurate and legible.
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Sign and date the form at the designated area to certify the accuracy of the information provided.
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Make a copy of the completed application form for your records before submitting it to the appropriate authority or insurance provider.

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Workers who have suffered work-related injuries or illnesses and are seeking to file a claim for workers' compensation benefits will need workers-compensation-application-pg1jpg. This form is required to initiate the application process and provide necessary details about the individual's employment and injury/illness.
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It is a document used to apply for workers' compensation benefits.
Employees who have been injured on the job and are seeking compensation benefits.
The form must be filled out completely and accurately, providing details about the injury and treatment.
The purpose is to request compensation benefits for work-related injuries.
Information such as the details of the injury, medical treatment received, and work restrictions.
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