FIRST FOLLOW-UP DOC
Date
*
/
Month
/
Day
Year
Date
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Claim Number
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Select your reason for following-up
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Please Select
Lack of Communication
My Letter
Payment of Benefits
Decision
My Request for Health Care Treatment
Implementation of the Appeal's Decision
Implementation of my WSIAT Decision
Date of first contact
*
DD/MM/YYYY
Signature
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Clear
Your Name
*
First Name
Last Name
WSIB Settlements
First Name
Last Name
Submit
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