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2. The third step would be to fill out all of the following blank fields: Names of witnesses, Name and phone number of health, Name and address of health care, Have you previously injured this, Yes Yes Yes, No No No, Worker signature, Completed by please print, Date, Complete the rest of this form and, Phone, FEIN, Employer, If worker leasing company list, and Address of principal place of.
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3. In this stage, examine Address where event occurred, Was injury caused by failure of a, Yes, Date employer knew of claim, Employer signature, Workers weekly wage, Regular Date, Name and title please print, Unknown, Date worker hired Modiied Date, Yes Yes, No No, Class code OSHA log case no, If fatal date of death, and If returned to modiied work is it. These will have to be completed with greatest precision.
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