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#22-003507-0003
Supplemental Questionnaire

Last Name
First Name

 

***Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.***


1.

Please describe the 2 years of experience (as previously indicated in the application), in work requiring knowledge of the function, organization, procedures and governing laws and regulations of the Workers' Compensation Commission. Please provide the name of the employer and the dates that the experience was gained (if you do not possess this work experience, enter N/A.)

2.

Please describe any experience you have processing workers' compensation claims. Please provide the name of the employer and the dates that the experience was gained (if you do not possess this work experience, enter N/A.)


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