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Failure to provide the information requested on this form will not result in the denial of your claim but may delay the processing of your claim. The voluntary release of your social security number enables the Board to ensure that information is associated with and quick action is taken on your claim. IF YOU HAVE QUESTIONS OR NEED ADVICE ABOUT YOUR CLAIM YOU MAY CALL OR VISIT THE NEAREST OFFICE OF THE WORKERS COMPENSATION BOARD. SI USTED TIENE PREGUNTAS O NECESITA CONSEJO SOBRE SU RECLAMACION ...

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