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Ny Md 3 Form
Carrier/Self-Insured Employer making objection:
Date Form MD -1 Mailed:
Basis for Objection:
Signature:________________________________ Tel. No.:
(Ink only - Use blue ballpoint pen if possible.)
Date:
Signer's Name and Title (Please Print):________________________________________________
TO THE SIGNER: The original should be sent directly to the Workers' Compensation Board at the address
shown at the top of this form. A copy of this objection must be sent to all parties in interest and the...
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