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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...Show details
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