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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Injured Worker Information' section. Enter your name, Social Security number, date of birth, address, and contact number. Ensure all details are accurate and clearly typed or printed.
Next, move to the 'Injury Information' section. Specify the date and town of injury, describe the injury and how it occurred, and indicate if you are a minor by checking the appropriate box.
Proceed to the 'Employer Information' section. Fill in your employer's name and address. If applicable, provide details about where the injury occurred if not on employer premises.
Finally, sign the form in the 'Signature of Injured Worker or Representative' section. Print your name and address below if someone else is signing on your behalf.
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