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Returned to Work Information

Congratulations on returning to work!

In order to remove you from our active file please provide us with the following information:

First Name  
Middle Initial  
Last Name  
Last four digits of SSN  
E-mail Address  
Date Returned to Work  
(mm/dd/yyyy)
Job Title  
Employer Name  
Employer Street Address  
City     
State  
Zip Code  
Hourly Pay/Salary  
Hours per Week  

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