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Click ‘Get Form’ to open it in the editor.
Begin by entering your OWCP number and telephone number in the designated fields. If you do not have an OWCP number, you may leave it blank.
Fill in your name, address, and marital status. Ensure that all information is accurate and complete for processing.
Provide details about the injury, including the date of injury, occupation, and whether you stopped work immediately after the incident.
Complete sections regarding your earnings at the time of injury and any medical attention received. Be thorough in describing how the accident occurred in section 24.
Review all entries for accuracy before signing. Use our platform’s tools to easily edit any mistakes.
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