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Last Date Worked Was The Employee Paid a Full Day s Wages on the Date Of Injury Was the Claim Form Provided Yes No On What Date By Whom To Whom Was the Injury Reported Were There Any Safety Hazards Involved Yes No If Yes Have They Been Corrected If Yes Explain Is There An Opportunity For Subrogation Or Third Party Recovery Does The Employer Find This To Be A Questionable Claim If So Why Is Employee Still Off Work Is the Employer Able to Accommodate Modified Duty What Date Did Employee Return To...

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