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SS9901-CS051213From: M ,1 ------------- -7 WPCQ �• FnF Lnn��l L� Ve hi c S InIP(P L (n f P ._ __ ±rrPOltGal Q�� � SUS_ m;GPZ_`.__,.d_� �PGr � - - -•- =a r v.Ja5 S� �cr�-i _ L Canc c >rvi Cr S4_ — - eMVoy __. - cp ;v a c _4i c� d R wn _ ? Pe o f � a 5k r uCI -u ril �4 �__1�.oa h • � Concre-Ft - _H m n --f hx I 12/13!2005 03: 1c' #W P.002/005 55 ggol (211 � 7 - cep n leepoO CA! e_f I� } Pc Fi -, e5,�ec) +-f—.Jaa G (A ) �f s OLC 6r2 Ye — u- - A__ J9 -- Of I CAU i J Fpal'l j F)4 ali ca Te r),o - Z e ve d �(C,+eA : Coc --- Et—L---3O-nkCf 4 ry) S; 71L .Rower c - f Pce 0 e —I- - Le E 5:� L s t3x , c covered Crwoore-6-1,".re�-- L ;cr}-ec.� h� IM 1, .� h� �e n- �e�- 5e�..__C_e._� nn , - 7 - o C -,- \4 2Loi-w-e —cca-tLe cl- Ft I -An: 12113/20115 03:1'_, #1547 P.004 n zex 1P -5 c. P,z vr��� 4�%ei ��Azy <dr F&'f7 57 a -ek 04 sir L� �O( / 1�E he we•\4 �z FicrreLn4- C-�,rc(e noLS c��efl j r>o�tCd 5 �i� ccf + - , v^J 5 f-rti'c`j-v�� h{�`] ��i^^p�nY ., � �L Curl c/C�C� Si?T ✓i2c � �D Cr g y e)� y y C - -_ i - i i i worksm - dTripcAw irjn Insurance Carrier and the injured employee. eEmployms0o not send this form to the Texas Worlalers' Compensation Commission, unless the Commission specifically Bequests a direct filing. jr - }7 15 [VMS F_IJ DOI 1 1 P G TWCC CLAIM # — CARRIER'S CLAIM EMPLOYER'S FIRST REPORT OF INJURY OR IUNESS L NLas t, Flrsl, M.I.) 2. Sear FU M 3. Sadw 9erurtfv N Hame Phone 5. Date at Birth (m-d - s- ( are ) X (0 - 8 09 5. Does the Emplapee Speak FA&h? If No, Spectly languap YES ❑ NO 7 Race WhNs Black ❑ 8r Hn k AdM ❑ Netiv American U Othe ❑ 9. Mallhig AQahetss Street or P.O. PC% rp S �C.0 -cr � �✓ city State ZIP Code County .SA�v �r�o�i%re TX 78�Q - 10. Madtl swim married ❑ VPgltiwed 0 we rated ❑ sinio 0 ow "Ad ❑ 5 dhildren 1Z. Spaus� N me 11. Number d Depen C .... LJ_ Ondors Name 1 14. Der�,,o� //k Mash & Add (Sheet or P.O. Box) Ck, Stale ZIP Code Ate, r - 5, Date of injury (md-y) 16, Time of Injury 117 Date Lost Time Began (m d yd P -- 18. Nature of Injury' 19. Far of Body Injured nI Exposer 20 How and Wh�y�In�jury/Illness Occurred (;{CLQ.) CENp uY(J� ri A4.020.sad "4wj Aoe� (fi-a t' I 21. Was ampkryee doing 6d YES his regular job? 22 Warlwge Location of Injury (stairs, dock, elc.i' ❑ NO{ 23. Addrm Where Injury or Fvown; Umvrred 649,11` j,ts ,{ - Name of huslne9a V Inddent umunrd on a business site Street or P.O Elm county tv ^- Ctly State ZIP Code 24. Cause of In)ury (fag, lool. machine, 21 Lill Zg i 26. Ratum to work dotelor MMOCled (m 12 Bid employee d1e7 29.5upervisory Name ' ,Q �7.A (�b Gt}�•+�/ ?9. Date Repalted (m -d -y) ❑ ? % �� -/3 _ - YES NO t - 30. Date of Flire Irnd -y) 31. as emP eves red or racruRad in Toxa::? 32. Pettgtlt of Serol in Current length o► Se In pager 0 1- 3 1 Y NO ❑ Mantes �� -- - 1( Ilonths lr / 34. Employe Payro Ctassifi Co catinn de __...- --- .__.._...._�_�.___ —_ 35.Occupation of Injured Worker 35. Rate at Pay at this JnD !— 37 Full Work Week is - 36. last Paycheck was: 39 Is employee an Owner, Partner, �� cr Corporate Mar? $ • /� Huudy .5 ee Wkly � Hnurs Days E 14, L 11 +)r _- !•lou or E rays YES ❑ N0& 40. Name and ME 01 P015"' Completing Form J 41 Name of Business 42 ©ueintl.z kidding Address and Telephone Number 43. Business Loration (If different !rani maaing addrem) Street or PA Rox Telephone Number and feet _ - -- e CeY Stale ZIP Cade CiiY State �,. - -,ZIP Cod d4. Federal ttlerttilfca tisni rnher nrr, Primary Standard Industrial Class�callon (SIC) Code' SpeclAc SIC V Texas Comptroller. Taxpayer No. -0 S_ `, d dlgi (a di); �v � <U, 5 1� -- " 48_ Workers' GOmperc5aMP InSUranue Company (r7 a go. you request accidenl pnwen(ion ser vices in past 12 months? Y L_I N O n If yen, did you re celu8 Ihem? YF.S n NO n 51 SlgnaRkm and 'Y (READ INSTRUMIONS ON INSTRUCTION SHEET REFORL SIGNING) 49 Policy Number 1WICC -1 (2 -91) 211MI ,., — —1 ro n7% —ar-1 oolnmrur_ .a. �:I IPnLY IN1 -1— 4r_1.1