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FORMCHECKBOX  This is a Lost Time claim. Please Process and Pay. Complete the following: Name of Injured Employee: FORMTEXT       Name of Company: FORMTEXT       Authorized Signature: FORMTEXT       Date: FORMTEXT        PLEASE NOTE: Regardless of whether or not you chose to pay medical costs, YOU MUST REPORT ALL CLAIMS to 3MA Claims Services, who will then report the claims to the Division of Workers Compensation. This How to Report a Claim form MUST be submitted with every report of injury. 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