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Oc 110a  Form

Oc 110a Form

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Social Security or Tax Identification Number and/or Date of Accident DB Discrimination PFL IF RELEASE IS AUTHORIZED FOR ADDITIONAL CASE FILE(S), IDENTIFY BELOW BY WCB/DB/DC/PFL CASE NUMBER AND/OR DATE OF ACCIDENT(S) INSTRUCTIONS: Submit original to the Workers' Compensation Board and retain a copy for your records. Authorization for disclosure of records for certain purposes is not valid under the law. See excerpt of WCL Section 110-a on the reverse of this form. This authorization is...
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