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C5 Form
VILLAGE)
INJURED PERSON'S
SOCIAL SECURITY NUMBER
ADDRESS (Include Apt. No.)
TELEPHONE NO.
PATIENT'S BIRTH DATE
EMPLOYER*
Indicate days of week & times
(AM or PM) when you are
available to testify.
INSURANCE
CARRIER
VFBL
*If treatment was under the VFBL or VAWBL show as "Employer" the liable political subdivision and check one:
VAWBL
and complete Items 3-23 below. If not, complete ALL items.
If you have filed a previous report, setting forth a history of the injury, enter...
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