Self-Insurance Provider's Initial Report
When the completed PIR is received by the employer, they must assign a claim number and adjudicate the claim. 1.CLAIM NUMBER 1. NAME OF SELF-INSURED EMPLOYER PATIENT INFORMATION. ADDRESS 2. NAME OF INJURED WORKER: FIRST MIDDLE LAST 3. WORKER’S TELEPHONE NO. CITY STATE ZIP 4. MAILING ADDRESS 5. SOCIAL SECURITY NUMBER 2. ................
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