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Date of Disability mm/dd/yyyy 10. Has employee been certified by U*S* Veterans Administration for any type of disability Yes No Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks report wages from the time worked and for the remaining weeks on this schedule substitute wages of a fellow employee in the same class of employment who has worked for one year or more. Year Week ...

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