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200 Front Street West Toronto ON M5V 3J1
 

Summary: Mail To:
200 Front Street West
Toronto ON M5V 3J1
OR Fax To:
416-344-4684
OR 1-888-313-7373
Worker's Report
of Injury/Disease (Form 6)
6 Claim Number
Please PRINT in black ink
A. Worker Information
Social Insurance NumberFirst NameLast Name
TelephoneAddress (number, street, apt., suite, unit)
City/Town Province Postal Code Alternate/Cell Phone
How long have you
been doing this job
for this employer?
Date you
started
with employer

  

Source: Abolmaesumi, Purang - School of Computing, Queen's University (Kingston)

 

Collections: Computer Technologies and Information Sciences