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The document is the BI-3 form, titled 'Employer’s Report of Injury,' used by employers to report workplace injuries to BrickStreet Insurance. It outlines the necessary information required from the employer regarding the injured employee, including personal details, injury specifics, and compliance with West Virginia Workers’ Compensation Law. The form must be completed accurately and submitted within five days of notification of an injury.

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Versions	Form popularity	Fillable & printable
2006	4.8 Satisfied (107 Votes)

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