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Get and Sign STATE of CALIFORNIA DWC DISTRICT OFFICE 2020-2022 Form
Check only one box ) ADJ DEU SIF UEF SAU INT RSU Companion Cases Specific Injury Case Number 2 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: DWC-CA form 10232.1 Rev. 5/2020 - Page 1 of 8 Specific Injury Case Number 3 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the...Show details
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