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Full Name
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First
Last
Employee Phone Number
Employer Business Name
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Employer Contact Name
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Employer Contact Phone
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Date of Injury
How much work has the employee missed?
How much work has the employee missed?
3 days or fewer
More than 3 days
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Wendy, Shaver Lake
“You guys are awesome!!! We are so happy to have you as our payroll folks.”
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