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Dwc Form 153 2006
Documentation may be required for eligibility. The signature must be notarized.
(Please type or print)
I. CLAIM FILE IDENTIFICATION.
Provide the following information to identify the requested claim file.
DWC or
IAB Number
Employee's Social
Security Number (last 4)
Employee’s Name
Employee's Date of Injury
X X X
--
X X
--
-Last
First
MI
Address
m
City
m
--
d
d
State
y
y
y
Zip Code
II. REQUESTOR INFORMATION. Provide the following information pertaining to the...
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