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* 1. Employer Name: (Please do not abbreviate your business name)

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* 2. What is your PA UC account number?
 (1234567)

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* 3. Employees Full Name

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* 4. Last 4 of the SS# - (Do not provide us with the full SS#. If you do not have the last 4 of the SS# do not report it on this site, because L&I needs the last 4 to shut down the claim)

T