Employees Claim For Compensation For A Work-Related Injury Or Occupational Disease {DWC-41}

American LegalNet, Inc. www.FormsWorkFlow.com 000002003004005006007btn013007004fr004016007007007007017020021022023024025022026027020021007030031032033034035036037 033031007036!033"037007#035$%033&''()007*%036 035007032033034007*033035$'031)036037 033031007032033034007036007+033034,-.'%036037'/0070300310"034&007033034007122"$036037 033031036%0073 )'036)'00743+*0075033034035-6789007:007025;<026=007>027023007002027023?t023021@007003027=At020021<022026027020007Bt020t>026022021007=024021022007Bt007>026;tC007D026022E007022Et007000026n026021026027020007027>007002027023?t023021F007003027=At020021<022026027020007G000026n026021026027020H007BI007022Et007026020J024023tC007t=A;027Itt007GI027024HK007027023007BI007<007At023021027020007<025022026020L007027020007022Et007026020J024023tC007t=A;027Itt@021007GI027024023H007BtE<;>007D026022E026020007MNO007POQR 007027>007022Et007026020J024023I007027023007D026022E026020007MN O007POQR 007>023027=007022Et007C<022t007I027024007?020tD007027023007021E027024;C007E<nt007?020027D020007022Et007026020J024023I007027023007C026021t<021t007=<I 007Bt007D027023?007023t;<022tCS007TUVWXX007L027027C007025<024 021t007tY026021022021007>027023007022Et007><026;024023t007022027007022026=t;I007>026;t007<007025;<026=K007027023007022Et007t=A;027It023007027023007022Et007t=A;027It023@021 007026020021024023<020025t007025<023023026t023007C027t021007020027022007025027020022t021022007022E t007025;<026=013007 TA027020007023t025t026A022007027>007I027 024023007025027=A;t022tC007000002003007Z027023=[004005006K007027023007027022Et023007020027022026025t007027>007I027024023007026020J024023IK007022Et007000026n026021026027020007D026;;007025 023t<022t007<007025;<026=007<020C007t021022<B;026021E007<007000002003007 025;<026=007020024=Bt023007>027023007I027024K007<020C007022Et007000026n026021026027020007D026;;007=<026;007026020>027023=<022026027020007023tL<023C026020L007D027023?t023021F 007025027=At020021<022026027020007026020007\tY<021007022027007I027024013007\E t007000026n026021026027020007D026;;007<;021027007020027022026>I007I027024023007t=A;027It023007<020C007022Et007t=A;027It023F021007D027023?t023021F007025027=At020 021<022026027020007026020021024023<020025t007025<023023026t023013007]^#*030`007030a ]b.c*b0301a]007a3007030a51.db0301a00751.007*1d^`#b030ae007bf#0073+* 0075033034035-678007e'031'034036%007030031)037034"2037 033031) 007 g*033035$%'037' 007036%% 007!033h')007 031007037i'0073+*0075033034035-678013 g017>007I027024007E<n t007j024t021022026027020021007<B027024022007025027=A;t022026020L007022E026021007>027023=K007A;t<021t007025<;;007I027024023007;027025<;007000026n026021026027020007Z026t;C007k>>026025t007<022007006[l004004[mn m[016004f0060130300310"034'/007#035$%033&'' 007030031032033034035036037 033031 007 g002027023?007X022<022 024021007026020>027023=<022026027020 o017>007 I027024007E<nt007023t022024023020tC007022027007I027024023007023tL024;<023007J027B007<020C007I027024007<023t007At023>027023=026020L007022Et007021<=t007C024022026t021007<021007I027024007Dt023t007B t>027023t007I027024023007026020J024023IK025E t025?007022Et007pbtL024;<023q007B027Y013 o017>007 I027024007E<nt007Btt020007023t;t<021tC007022027007D027023?007D026022E007023t021022023026025022026027020021007BI007<007C027025022027023K007025Et025?007pbt021022023026025022tC013q 0300310"034&007030031032033034035036037 033 031 007 g:020007rNstRP 007026 021007C<=<Lt007022027007I027024023007B027CI007022E<022007D<021007025<024021tC007BI007<007021026020L;t007026020025026Ct020022K007<025025026Ct020022K007027023007tnt020022013 g:020007MuutvQ wrMNQx007yrzOQzO 007026021007<020007026;;020t021021007027023007026020J024023I007023t;<022tC007022027007027023007025<024021tC007BI007022Et007D027023?007I027024007C027K007<020C007=<I007026020025;024C t007026020J024023026t021007022027007I027024023B027CI007022E<022007 <023t007022Et007023t021024;022007027>007023tAt022026022026nt007<025022026n026022026t021007I027024007At023>027023=tC007027020007022Et007J027B007027nt023007<007At023026027C007027>007022026=t013 #035$%033&'034007030031032033034035 036037 033031 007 g{023027n026Ct007026020 >027023=<022026027020007<B027024022007I027024023007t=A;027It023007<022007022Et007022026=t007I027024007Dt023t007026020J024023tC 013 30332037033034007030031032033034035036037 033 031 007 g017>007I027024007<;023t <CI007E<nt007<007D027023?t023021F007025027=At020021<022026027020007022023t<022026020L007C027025022027023K007A023027n026Ct007022Et007020<=t007<020C007<CC023t021021007027>007022Et007C027025022 027023013g017>007I027024007<023t007 025027nt023tC007024020Ct023007<007D027023?t023021F007025027=At020021<022026027020007Et<;022E025<023t007020t022D027023?K007A023027n026Ct007022Et007020<=t007027>007022Et007020t022D027023? 013*0330310370362037 031|007b'h036)0073'$036034037035'031037007033032007030031)"0340360312'}0073 ~ ) 033031007033032007+033034,'034)007*033035$'031 )036037 033031 007017>007I027024007E<nt007j024t021022026 027020021007<B027024022007>026;;026020L007027024022007022E026021007>027023=007027023007D027023?t023021F007025027=At020021<022026027020007026020007\tY<021K007A;t<021t007025<;;007I027024023007;027025<;007000026n026021026 027020007Z026t;C007k>>026025t007<022007006[l004004[mnm[016004f006013007a1b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merican LegalNet, Inc. www.FormsWorkFlow.com