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| Phone: |
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| Address: |
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Date of Injury:
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What injuries did
you suffer?
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Please describe how your injury occurred:
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In what state did
this happen?
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I was denied or
they terminated my workers compensation |
Do you believe your employer has submitted fraudulent information to the government?
Yes
No
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Do you think this fraud is still occurring?
Yes
No
Please describe any government fraud committed by your employer that you know of:
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Subscribe me to "Workers Comp News", the official employment law newsletter of WORKERS-COMP-NEWS.COM:
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