Example: confidence
WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR …
DATE PREPARED PREPARER'S NAME TITLE PHONE NUMBER ... DATE RETURN(ED) TO WORK HOSPITAL OR OFFSITE TREATMENT (NAME & ADDRESS) LOST TIME ANTICIPATED ... incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. Page 3 of 5. ACORD 4 (2013/01) Page 4 of 5 ...
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