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WY Report of Injury v1 - Wyoming Workforce

Department of Workforce Services Division of Workers' Compensation Report of Injury INJRPT IMPORTANT: PLEASE COMPLETE THE BACKSIDE OF THIS FORM Revised 11/11 EMPLOYER INFORMATION Please use BLACK ink. Do not cross zeros or sevens Claim Number: BUSINESS NAME WORK COMP EMPLOYER #

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  Report, Injury, Wyoming, Report of injury

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