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DLSE-NTE (rev 4/2012) Revised 06/2014 WORKERS’ COMPENSATION. Insurance Carrier’s Name: Address: Telephone Number: Policy No.: _____ Self-Insured (Labor Code 3700) and Certificate Number for Consent to Self-Insure: _____ ACKNOWLEDGMENT OF RECEIPT (PRINT NAME of Employer representative) (SIGNATURE of Employer representative) ................
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