Information Form
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Email address *
Name *
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Address
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Phone number
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Employer
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Date of Accident
MM
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DD
/
YYYY
Location of Accident (Include State & County)
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Job Responsibilities
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Work Being Performed When Injury Occurred
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Description of Accident
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Body Parts Injured
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Medical Treatment
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Lost Wages
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Reason Given for Denial (if applicable)
Your answer
Other Comments or Questions
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