*Click in document to fill out form. FAX COVER SHEET To: Claims Department From: Company: Holland Date: Fax: 866-846-6492 Total No. of pages (including cover):
C 5 Application Attachment Cover Sheet Complete this cover sheet and submit via: E-mail- hr@losrios.edu Fax - (916) 286.3655 Drop Off or Mail - 1919 Spanos Court (Human Resources) Sacramento 95825
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COVER SHEET FOR REPORT OF INDEPENDENT MEDICAL EXAMINATION. IME-4 (5-18) A copy of each report of Independent Medical Examination shall be submitted on the same day and in the same manner to the Workers' Compensation Board, the
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