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C 2f Form
Information:
• Insurer Name – the name of your Workers’ Compensation Insurer or Self-Insured Group name.
• Insurer ID – Carrier Code Number (W Number) issued by the Workers' Compensation Board. If you do not know the W
number, contact your insurer.
• Name – the name of the Claim Administrator (claim adjusting office handling the claim).
• Info/Attn –any additional pertinent contact information for the Claim Administrator.
• Address, City, State, Postal Code, & Country – address of claims...
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