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Workers Comp 100 Form
The date of injury; (b) Death; (c) Specific losses. In case of death, an
employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures.
I. EMPLOYEE DATA
1. Social Security Number
2. Date of injury
3. Employee name (Last, First, MI)
4. Address (Number & Street)
8. Date of birth (MM/DD/YYYY)
9. Sex
Male
12. Tax filing status:
A. Single
5. City
6. State
7. ZIP Code
10. Number of dependents
11. Telephone...
Show details
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