1 FORM C, 1 FORM A, 1 FORM B •CONTACT RATING 40A（AC240V/DC30V
Form C 1. To file a claim for compensation, see reverse. Register for a new account.
Web supervisor’s signature date signature of injured or disabled employee. To file a claim for compensation, see reverse. Register for a new account. This report is required of every employing unit, and will be used to determine liability under.
Web supervisor’s signature date signature of injured or disabled employee. Web supervisor’s signature date signature of injured or disabled employee. Register for a new account. This report is required of every employing unit, and will be used to determine liability under. To file a claim for compensation, see reverse.
