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Workers Compensation Claimant Information Packet
WCB Case Number (if you know it):. Fill out this form to apply for workers compensation benefits because of a work injury or work-related illness. Type or.
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Printing T C)(S C4
If the claimant is not represented, a copy must be sent to the claimant. 2. Please ask your patient for his/her WCB Case Number and the Insurance Carriers Case
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CLAIM FOR COMPENSATION IN A DEATH CASE FORM C-62
Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc. d. Itemized funeral bill. W.C.B. CASE NO.(if known). CARRIER CASE
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