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OC | Inland Empire | Los Angeles County

Supplemental Job Displacement Benefit Voucher

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When you are completing the above form, you are certifying that you were injured at work, or a family member of an injured worker. You also further certify that you are not the employee of a workers compensation insurance company, employer, contractor, or a lawyer or employee of a law firm representing insurance companies or employers in workers’ compensation cases. You are also subscribing to our newsletter, which you can opt out at any time.