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 Workers Comp Form 1a 1 2002-2023

Workers Comp Form 1a 1 2002-2023

Create a custom form workers compensation injury 2002 that meets your industry’s specifications.

INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED ADDRESS (INCL. ZIP) SEX MARITAL STASIS STATE OF HIRE OCCUPATION TITLE EMPLOYMENT STATUS PHONE # OF DEPENDENTS RATE DAY MONTH $PER: WEEK NCCI CLASS CODE OTHER DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? YES DID SALARY CONTINUE? NO OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK AM DATE OF INJURY/ILLNESS TIME OF...
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