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Workers Compensation Claim Reporting Worksheet and GuideWe will produce and submit the necessary state forms and filings.DO NOT DELAY IN REPORTING IF YOU DO NOT HAVE ANSWERS TO ALL THE QUESTIONS.PLEASE EMAIL YOUR COMPLETED FORM TO [email protected] OR CALL 1.800.238.6225.!ACCOUNT / ACCIDENT INFORMATIONPREPARER’S PHONE NUMBERPREPARER’S TITLEPREPARER’S NAMEEMPLOYMENT STATESUBSIDIARY (COMPANY) NAMESUBSIDIARY (COMPANY) ADDRESS (STREET, CITY, STATE & ZIP)SUBSIDIARY (COMPANY) MAILING ADDRESS (STREET, CITY, STATE & ZIP) SAMEDID THE ACCIDENT OCCUR AT THE LOCATION ADDRESS? YES NO IF NO, ADDRESS WHERE ACCIDENT OCCURREDPARENT COMPANY / INSURED’S NAMELOCATION CODEPOLICY SYMBOL AND NUMBERNATURE OF BUSINESSDATE OF INJURYTIME OF INJURYACCIDENT DESCRIPTIONEMPLOYEE INFORMATIONINJURED EMPLOYEE’S SOCIAL SECURITY NUMBER:EMPLOYEE’S NAME (FIRST, MI, LAST)GENDER MALE FEMALEPRIMARY LANGUAGEDATE OF BIRTHEMPLOYEE’S MAILING ADDRESSEMPLOYEE’S PHONE NUMBEREMPLOYEE’S HOME ADDRESS (IF DIFFERENT FROM MAILING...