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Fax Cover Sheet

Document Number: WKC-17843-E

Description: This form is to be used when submitting documents on non-litigated claims.

Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word).

Content Contact: Lynn Weinberger

Document Attachments: WKC-17843-E (Electronic Version - Word/32 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.