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Workers' Compensation Law

Employer Workers' Compensation Contact Form

Employee

Employee Name

E-mail Address

Home Phone Number

Employee Address

City

State

Zip

Cellular or Pager

Work Phone

Company

Company Name

E-mail Address

Company Address

City

State

Zip

Phone Number

Fax Number

Company Workers' Compensation Insurance Carrier

Insurance Carrier Address

City

State

Zip

Phone Number

Fax Number

E-mail Address

Policy Number

Number of Employees

Type of Business

Nature of Accident or Illness

Did an Accident Occur on Employer Premises?
Yes No 

Has Employee Filed for Workers' Compensation Before?
Yes No 

If Yes, When?

Nature of Previous Claim

Issues and Comments

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Office Locations

The Law Firm of Peters & Wasilefski

2931 North Front Street
Harrisburg, Pennsylvania 17110

Telephone: (717) 260-3483
Fax: (717) 238-7750
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