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Workers Compensation First Notice Of Loss









  • EMPLOYER | INSURED INFORMATION

  • EMPLOYEE INFORMATION

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  • OCCURRENCE | TREATMENT

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    The 1st day on which the claimant originally lost time from work due to the injury/disease
  • Name of the individual at the Employer's Premises to be contacted for additional information
  • Nature of injury or illness (eg. Lacerations to the forearm)
  • Indicate the part of body (eg. right forearm, lower back)
  • Describe the specific activity
  • What was the employee doing?
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    Select All That Apply
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