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Day Yr. 4. Name of Injured/Deceased Employee Type or print - first M. I. last Hour AM PM 5. Employee s Address No* street city state ZIP code Telephone 6. Injury is Reported Under the Following Act Mark one 7. Indicate Where Injury Occurred Longshore Act only Mark one Building Way F Marine Railway G Outer Continental Shelf Lands Act D Marine Terminal E Nonappropriated Fund Instrumentalities Act C Dry Dock Other Adjoining Area 9. Date of Birth M 10. Social Security No* Required by Law 11. Did In ...

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