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Notice of Injury

Step 1: General Information

Employer Name *

State Employee Hired In *

Date of Accident *

Policy Number

Employee SSN# *

Employee’s Supervisor *

Accident Location *

Employer Phone *

Employer Address *

Employer Address

Line 1

Line 1

Line 2

Line 2

Employer City

Employer City

Employer State

Employer State

Employer Zip

Employer Zip

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