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Fill and Sign the Virginia Workers Compensation Commission Edi Implementation Guide Form

Fill and Sign the Virginia Workers Compensation Commission Edi Implementation Guide Form

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In str u ctio n: T his i s a m odel l e tte r. A dap t t o f it y our f a cts a n d c ir c u m sta n ces. D ate Worker’s Compensation CommissionAddre ss L in eC ity , S ta te Z ip C odeRE: MWCC No: Claimant: Employer: Carrier: DOA: Dear : This is to notify you that I have been employed by the above named claimant concerning injuries received on the above date. I have enclosed a copy of my employment contract for filing and approval. I request that a copy of anything that may be in the claim file be sent to me as soon as possible. I have enclosed copies of all medical reports in my possession.Thank you for your cooperation in this matter. If you have any questions please give me a call at the above number. Very truly yours, Enclosurecc:R etu rn a d dre ss:N am eAddre ss L in e 1A ddre ss L in e 2C ity , S ta te Z ip C ode

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