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[]
[null,"Claim Reporting Form"]
[null,"workers' compensation"]
[null,"Name of person reporting",null,null,"Telephone Number",null,null,"For report only"]
[null,"Dean Myers",null,null,"214-647-9629"]
[]
[null,"Address information"]
[null,"Name and address of the company",null,null,null,null,"Client name and location"]
[null,"PDS Tech, Inc."]
[null,"1925 John Carpenter Freeway, Suite 550"]
[null,"Irving TX, 75063"]
[null,"Contact name",null,null,null,null,"Policy number",null,null,"Site code"]
[null,"Dean T. Myers Corporate Risk Manager",null,null,null,null,"WC 9298950-15"]
[null,"Telephone number"]
[null,"214-647-9600 Ext. 10159"]
[]
[null,"Accident information"]
[null,"Date of accident",null,"Time of accident",null,"Address where incident occurred",null,null,null,"County"]
[]
[]
[null,"Please give a description of the incident"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"If yes, who"]
[]
[]
[]
[null,null,null,null,null,null,"In the event of a fatality, what is your OSHA number?"]
[]
[]
[]
[]
[null,"Claimant information"]
[null,"What is the name and address of the injured party"]

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[]
[]
[]
[]
[]
[null,null,"Employment information"]
[null,null,"Employment status (check one)"]
[]
[]
[]
[null,null,"Contractors Email ",null,null,null,"PDS Employee Number"]
[null,null,null,null,null,null,null,null,"Does this claim involve any Maritime Operation"]
[]
[null,null,"Date returned to work or expected return"]
[null,null,null,null,null,"Hourly or weekly wage",null,null,"Wage listed?",null,"Employee is eligible for(please check)"]
[null,null,null,null,null,null,"Hour","Week"]
[]
[null,null,"Weeks worked in last twelve months",null,null,null,null,null,"Employer notified on what date"]
[]
[]
[null,null,"Injury information"]
[null,null,"Were any injuries incurred?",null,null,"What part of the body?",null,null,null,null,"What treatment was given (please check)"]
[]
[]
[null,null,"Give a description of the injuries"]
[]
[]
[]
[]
[]
[]
[null,null,"Name and address of treating physician",null,null,null,null,null,null,"Name and address of treating hospital/clinic"]
[]
[]
[]
[]
[]
[null,null,"Phone number of treating physician",null,null,null,null,null,null,"Phone number of treating hospital/ clinic"]
[]
[]
[null,null,"Witness Information"]
[null,null,"Name and address of a witness to the incident",null,null,null,null,null,null,"Phone number where witness can be reached"]
[]
[]
[]
[]
[]
[]
[null,null,"Anything related to the incident you would like to add"]