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Worker's Compensation Case Demographics
Patient name?
*
Who was your employer at the time of your injury?
*
What was your employers address?
*
What was your job title at the time of your injury?
*
Claim Number
*
Date of Injury?
*
Adjuster name
*
Adjusters phone Number
*
Adjusters fax number
*
Attorney's Name
Attorney's phone number
Attorney's fax number
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