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Non Covered Employers Report Of Occupational Injury Or Illness (Supplement) DWC-7 Supp - Texas

Non Covered Employers Report Of Occupational Injury Or Illness (Supplement) Form. This is a Texas form and can be used in Employer Workers Compensation .
 Fillable pdf Last Modified 6/19/2006
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EMPLOYER DATA INJURY DATA 1.Employer's Business Name 2. Federal Employer ID No. REPORT FOR MONTH OF: YEAR: ________ 3 Employee's Name First 16. Sex M F MI 17. DOB (m-d-y) 10. Date of Injury/Illness (m-d-y) 22. Description of Incident 11. Employee 6 Digit NAICS code 12. Equipment 13. Nature of INJ/ILL 14. Body Part(s) Affected Last 15. Social Security Number 23. Lost Time >1 Day - 7 Days 8 Days or More 18. Race/Ethnic Identification White (not of Hispanic origin) Black (not of Hispanic origin) 19. Cause of Injury Hispanic Asian or Pacific Islander American Indian or Alaskan Native 20. Location of Injury (see instructions) A B 21. Employee's Occupation C 21a. Hourly Wage OCC NAT BOD 10. Date of Injury/Illness 11. Employee 6 Digit (m-d-y) NAICS code First 16. Sex M 18. Race/Ethnic Identification White (not of Hispanic origin) Black (not of Hispanic origin) 19. Cause of Injury Hispanic Asian or Pacific Islander American Indian or Alaskan Native 20. Location of Injury (see instructions) A B C 21a. Hourly Wage OCC NAT BOD 11. Employee 6 Digit NAICS code SRCE 12. Equipment ACCDT AOS 26. DWC USE ONLY F MI 17. DOB (m-d-y) 22. Description of Incident SRCE 12. Equipment ACCDT AOS 13. Nature of INJ/ILL 26. DWC USE ONLY 24. Occupational Disease YES 25. Fatality YES Date (m-d-y) NO NO 4 Employee's Name Last 14. Body Part(s) Affected 15. Social Security Number 23. Lost Time >1 Day - 7 Days 8 Days or More 24. Occupational Disease YES NO 25. Fatality YES Date (m-d-y) NO 21. Employee's Occupation 5 Employee's Name First 16. Sex M F MI 17. DOB (m-d-y) 10. Date of Injury/Illness (m-d-y) 22. Description of Incident 13. Nature of INJ/ILL 14. Body Part(s) Affected Last 15. Social Security Number 23. Lost Time >1 Day - 7 Days 8 Days or More 18. Race/Ethnic Identification White (not of Hispanic origin) Black (not of Hispanic origin) 19. Cause of Injury Hispanic Asian or Pacific Islander American Indian or Alaskan Native 20. Location of Injury (see instructions) A B 21. Employee's Occupation C 21a. Hourly Wage OCC NAT BOD SRCE ACCDT AOS date stamp 26. DWC USE ONLY 24. Occupational Disease YES 25. Fatality YES Date (m-d-y) NO NO DWC FORM -7 SUP (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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