The village of Little Diomede Island.

Workers’ Compensation Employer Form

Workers' Compensation Employer Form

Employer Contact Name
Employer Mailing Address(Required)
Employee Name(Required)
Employee Address(Required)
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MM slash DD slash YYYY
MM slash DD slash YYYY
Time of Injury / Illness
:
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY