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ADDRESS FILING ENTITY: Employer Carrier INSURANCE CARRIER'S NAME AND MAILING ADDRESS Other (If "Other", give name and address.) CARRIER ID NUMBER CARRIER CASE NUMBER WWC POLICY NUMBER INJURED EMPLOYEE (First Name, Middle Initial, Last Name) EFFECTIVE DATE OF POLICY EMPLOYEE'S ADDRESS (Street No. & Name, Apt No., City, State & Zip Code) UNION NAME & LOCAL NUMBER EMPLOYEE'S SOCIAL SECURITY NUMBER DATE OF BIRTH TELEPHONE NUMBER SEX SPECIFIC DETAILS AS TO OCCURRENCE OF INJURY AND...

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