![](https://www.pdfsearch.io/img/4c9b21df94a9198407108ea4cf873bab.jpg) Date: 2013-04-03 13:07:55
| | Workers’ Compensation Wage Designation Form I acknowledge, accept and understand that the Louisiana Construction & Industry Self Insurers Fund has based my annual workers’ compensation premium by using $23,700 as myAdd to Reading ListSource URL: lciwc.comDownload Document from Source Website File Size: 59,03 KBShare Document on Facebook
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