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Iowa First Report of Injury Form
City, State, & Postal Code:
Mailing Address, City, State, & Postal Code:
Industry Code:
Employer Type Code:
__ Employer (E)
__ Lessor (L)
Insured Location Number:
Nature of Business:
Employer Contact Name and Business Phone Number:
Insured FEIN:
Insured Postal Code:
Policy/Contract Number:
Coverage Effective Date:
POLICY
Insured Name (parent company if different than employer):
Self Insurance License/
Certificate Number:
Coverage Expiration Date:
Employee Name (First, Middle, Last,...
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