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OUT OF STATE WORKERS COMPENSATION RENEWAL (EXCLUDING WASHINGTON, N. DAKOTA, OHIO, CANADA & WYOMING WHICH ARE SEPARATE POLICIES) RETURN COMPLETED REPORT to: Elaine.Noot@adm.idaho.gov
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AGENCY/DEPARTMENT NAMEEMPLOYEE NAMEEMPLOYEE JOB TITLEEMPLOYEE'S HIRE DATEIF APPLICABLE, EMPLOYEE'S TERMINATION DATEEMPLOYEE'S SPECIFIC JOB DUTIESESTIMATED TOTAL ANNUAL SALARY WC Class CodeWORK STATE(S) WORK ADDRESS-CITY, STATE ZIPSTATE OF DOMICILE IF DIFFERENT THAN WORK STATESTATE OF DOMICILE ADDRESS -(CITY, STATE, ZIP) IF DIFFERENT THAN WORK ADDRESS UNEMPLOYMENT INSURANCE NUMBERNOTES, IF APPLICABLE.
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