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Get and Sign Department of Employment Services LABOR Washington, D C  Form

Get and Sign Washington Dc Department of Labor Form

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DCWC WITH THIS OFFICE. FAILURE TO PAY BENEFITS UNLESS YOU CONTROVERT THE EMPLOYEE S RIGHT TO BENEFITS WILL SUBJECT YOU TO PENALTIES UNDER THE ACT. 53-0199507 Employer Identification No. 041-543-470 Insurer No. EMPLOYEE S CLAIM APPLICATION Employee Name and Address Policy No. 2005012906881 Insurer Name PMA Insurance Group 380 Sentry Parkway Blue Bell PA 19422-0754 Gallaudet University Human Resources College Hall Room 105 800 Florida Ave NE Washington DC 20002 NOTICE TO EMPLOYEE A CLAIM FOR...
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