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STATEMENT OF BENEFITS PAIDOfficial Form 141Revised 06/2024TO BE COMPLETED BY INSURANCE CARRIER OR REINSURED EMPLOYER
NOTICE TO INJURED WORKER: This form is to notify you, the injured worker, of the
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What is official form 141?
Official form 141 is a document used for reporting specific information to a governing body.
Who is required to file official form 141?
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The purpose of official form 141 is to ensure compliance with regulations and to provide necessary data to the governing body.
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