%PDF-1.4
%
670 0 obj
<<
/Linearized 1
/O 674
/H [ 8054 1043 ]
/L 219453
/E 124188
/N 2
/T 205934
>>
endobj
xref
670 302
0000000016 00000 n
0000006392 00000 n
0000006748 00000 n
0000007916 00000 n
0000009097 00000 n
0000009498 00000 n
0000010569 00000 n
0000010793 00000 n
0000010941 00000 n
0000011176 00000 n
0000011322 00000 n
0000011557 00000 n
0000011703 00000 n
0000011914 00000 n
0000012060 00000 n
0000012295 00000 n
0000012441 00000 n
0000012655 00000 n
0000012802 00000 n
0000013029 00000 n
0000013176 00000 n
0000013404 00000 n
0000013551 00000 n
0000013786 00000 n
0000013932 00000 n
0000014158 00000 n
0000014304 00000 n
0000014533 00000 n
0000014680 00000 n
0000014894 00000 n
0000015041 00000 n
0000015255 00000 n
0000015401 00000 n
0000015615 00000 n
0000015762 00000 n
0000016004 00000 n
0000016151 00000 n
0000016394 00000 n
0000016541 00000 n
0000016784 00000 n
0000016931 00000 n
0000017174 00000 n
0000017321 00000 n
0000017543 00000 n
0000017689 00000 n
0000017898 00000 n
0000018046 00000 n
0000018261 00000 n
0000018409 00000 n
0000018618 00000 n
0000018765 00000 n
0000018998 00000 n
0000019145 00000 n
0000019348 00000 n
0000019495 00000 n
0000019722 00000 n
0000019869 00000 n
0000020098 00000 n
0000020245 00000 n
0000020479 00000 n
0000020624 00000 n
0000020852 00000 n
0000020998 00000 n
0000021229 00000 n
0000021375 00000 n
0000021639 00000 n
0000021785 00000 n
0000022009 00000 n
0000022155 00000 n
0000022380 00000 n
0000022526 00000 n
0000022759 00000 n
0000022906 00000 n
0000023141 00000 n
0000023287 00000 n
0000023511 00000 n
0000023658 00000 n
0000023883 00000 n
0000024030 00000 n
0000024235 00000 n
0000024382 00000 n
0000024586 00000 n
0000024733 00000 n
0000024938 00000 n
0000025084 00000 n
0000025322 00000 n
0000025469 00000 n
0000025706 00000 n
0000025853 00000 n
0000026086 00000 n
0000026233 00000 n
0000026455 00000 n
0000026601 00000 n
0000026823 00000 n
0000026970 00000 n
0000027205 00000 n
0000027352 00000 n
0000027587 00000 n
0000027734 00000 n
0000027969 00000 n
0000028116 00000 n
0000028327 00000 n
0000028474 00000 n
0000028685 00000 n
0000028831 00000 n
0000029054 00000 n
0000029201 00000 n
0000029424 00000 n
0000029571 00000 n
0000029788 00000 n
0000029935 00000 n
0000030150 00000 n
0000030297 00000 n
0000030516 00000 n
0000030662 00000 n
0000030882 00000 n
0000031029 00000 n
0000031277 00000 n
0000031423 00000 n
0000031671 00000 n
0000031817 00000 n
0000032037 00000 n
0000032184 00000 n
0000032415 00000 n
0000032562 00000 n
0000032785 00000 n
0000032932 00000 n
0000033155 00000 n
0000033302 00000 n
0000033518 00000 n
0000033664 00000 n
0000033879 00000 n
0000034026 00000 n
0000034242 00000 n
0000034389 00000 n
0000034610 00000 n
0000034755 00000 n
0000034993 00000 n
0000035138 00000 n
0000035363 00000 n
0000035509 00000 n
0000035734 00000 n
0000035880 00000 n
0000036082 00000 n
0000036229 00000 n
0000036434 00000 n
0000036581 00000 n
0000036799 00000 n
0000036945 00000 n
0000037165 00000 n
0000037311 00000 n
0000037527 00000 n
0000037673 00000 n
0000037916 00000 n
0000038064 00000 n
0000038312 00000 n
0000038459 00000 n
0000038700 00000 n
0000038848 00000 n
0000039090 00000 n
0000039238 00000 n
0000039487 00000 n
0000039634 00000 n
0000039879 00000 n
0000040024 00000 n
0000040269 00000 n
0000040414 00000 n
0000040641 00000 n
0000040787 00000 n
0000041014 00000 n
0000041161 00000 n
0000041387 00000 n
0000041534 00000 n
0000041793 00000 n
0000041938 00000 n
0000042197 00000 n
0000042342 00000 n
0000042573 00000 n
0000042720 00000 n
0000042939 00000 n
0000043085 00000 n
0000043312 00000 n
0000043459 00000 n
0000043684 00000 n
0000043829 00000 n
0000044054 00000 n
0000044199 00000 n
0000044423 00000 n
0000044568 00000 n
0000044794 00000 n
0000044940 00000 n
0000045165 00000 n
0000045310 00000 n
0000045504 00000 n
0000045651 00000 n
0000045853 00000 n
0000046000 00000 n
0000046246 00000 n
0000046394 00000 n
0000046622 00000 n
0000046769 00000 n
0000047000 00000 n
0000047147 00000 n
0000047381 00000 n
0000047528 00000 n
0000047774 00000 n
0000047921 00000 n
0000048138 00000 n
0000048285 00000 n
0000048500 00000 n
0000048647 00000 n
0000048865 00000 n
0000049012 00000 n
0000049241 00000 n
0000049388 00000 n
0000049612 00000 n
0000049760 00000 n
0000049986 00000 n
0000050134 00000 n
0000050297 00000 n
0000050444 00000 n
0000050665 00000 n
0000050812 00000 n
0000051063 00000 n
0000051210 00000 n
0000051373 00000 n
0000051520 00000 n
0000051683 00000 n
0000051830 00000 n
0000052064 00000 n
0000052210 00000 n
0000052444 00000 n
0000052590 00000 n
0000052813 00000 n
0000052960 00000 n
0000053175 00000 n
0000053322 00000 n
0000053539 00000 n
0000053686 00000 n
0000053900 00000 n
0000054047 00000 n
0000054268 00000 n
0000054416 00000 n
0000054605 00000 n
0000054752 00000 n
0000054941 00000 n
0000055088 00000 n
0000055278 00000 n
0000055424 00000 n
0000055649 00000 n
0000055796 00000 n
0000056022 00000 n
0000056169 00000 n
0000056407 00000 n
0000056553 00000 n
0000056791 00000 n
0000056937 00000 n
0000057167 00000 n
0000057314 00000 n
0000057544 00000 n
0000057691 00000 n
0000057923 00000 n
0000058069 00000 n
0000058313 00000 n
0000058459 00000 n
0000059004 00000 n
0000059045 00000 n
0000059261 00000 n
0000059821 00000 n
0000060045 00000 n
0000060075 00000 n
0000060098 00000 n
0000061550 00000 n
0000061573 00000 n
0000062894 00000 n
0000062917 00000 n
0000064228 00000 n
0000064251 00000 n
0000065557 00000 n
0000065580 00000 n
0000066815 00000 n
0000066838 00000 n
0000068226 00000 n
0000068249 00000 n
0000069532 00000 n
0000069555 00000 n
0000070915 00000 n
0000071006 00000 n
0000071026 00000 n
0000071096 00000 n
0000071184 00000 n
0000071254 00000 n
0000071327 00000 n
0000071534 00000 n
0000074212 00000 n
0000096146 00000 n
0000123550 00000 n
0000123623 00000 n
0000123702 00000 n
0000123775 00000 n
0000008054 00000 n
0000009075 00000 n
trailer
<<
/Size 972
/Info 667 0 R
/Root 671 0 R
/Prev 205923
/ID[<960f924146077ca5cc40ec027c61dc82><819e22ce3400f0e141620ccb12a61b1e>]
>>
startxref
0
%%EOF
671 0 obj
<<
/Type /Catalog
/Pages 668 0 R
/Metadata 669 0 R
/OpenAction [ 674 0 R /XYZ null null null ]
/PageMode /UseNone
/PageLabels 666 0 R
/StructTreeRoot 673 0 R
/PieceInfo << /MarkedPDF << /LastModified (D:20060203165428)>> >>
/LastModified (D:20060203165428)
/MarkInfo << /Marked true /LetterspaceFlags 0 >>
/AcroForm 672 0 R
>>
endobj
672 0 obj
<<
/Fields [ 676 0 R 678 0 R 680 0 R 682 0 R 684 0 R 686 0 R 688 0 R 690 0 R 692 0 R
694 0 R 696 0 R 698 0 R 700 0 R 702 0 R 704 0 R 706 0 R 708 0 R
710 0 R 712 0 R 714 0 R 716 0 R 718 0 R 720 0 R 722 0 R 724 0 R
726 0 R 728 0 R 730 0 R 732 0 R 734 0 R 736 0 R 738 0 R 740 0 R
742 0 R 744 0 R 746 0 R 748 0 R 750 0 R 752 0 R 754 0 R 756 0 R
758 0 R 760 0 R 762 0 R 764 0 R 766 0 R 768 0 R 770 0 R 772 0 R
774 0 R 776 0 R 778 0 R 780 0 R 782 0 R 784 0 R 786 0 R 788 0 R
790 0 R 792 0 R 794 0 R 796 0 R 798 0 R 800 0 R 802 0 R 804 0 R
806 0 R 808 0 R 810 0 R 812 0 R 814 0 R 816 0 R 818 0 R 820 0 R
822 0 R 824 0 R 826 0 R 828 0 R 830 0 R 832 0 R 834 0 R 836 0 R
838 0 R 840 0 R 842 0 R 844 0 R 846 0 R 848 0 R 850 0 R 852 0 R
854 0 R 856 0 R 858 0 R 860 0 R 862 0 R 864 0 R 866 0 R 868 0 R
870 0 R 872 0 R 874 0 R 876 0 R 878 0 R 880 0 R 882 0 R 884 0 R
886 0 R 890 0 R 892 0 R 898 0 R 900 0 R 902 0 R 906 0 R 910 0 R
918 0 R 920 0 R 922 0 R 924 0 R 926 0 R 928 0 R 930 0 R 932 0 R
904 0 R 908 0 R 14 0 R 15 0 R 16 0 R ]
/DR << /Font << /ZaDb 11 0 R /Helv 12 0 R >> /Encoding << /PDFDocEncoding 13 0 R >> >>
/DA (/Helv 0 Tf 0 g )
>>
endobj
673 0 obj
<<
/Type /StructTreeRoot
/RoleMap 17 0 R
/ClassMap 20 0 R
/K 374 0 R
/ParentTree 648 0 R
/ParentTreeNextKey 2
>>
endobj
970 0 obj
<< /S 530 /V 1161 /L 1473 /C 1489 /Filter /FlateDecode /Length 971 0 R >>
stream
HTmlUonZKwٙݦ3X*jJ@րi*w)V4BBvLJ,jtiHfn uՈ?tj 2$
nLcG3478;h!$*i y/6neIkCJ;NqP&$Ml$m;la-_*dlZ3HNU,`'XvBjR1F T $
Fl
WXezRèpRl<bl "l=[m<凍FH =<%PFo@
ЫIړHNBJA H.+s-;8QQ<Ζn 57Wye kэjS\bqLvX
)*&A;C@BAlju4,!7PWh~~Zro#ocYV p\vCAM?mc]4_mݘx*ѓDŵUu5Z|غ]<~+n~7|WOo[OnL뽟32P0^v{L=
v+'.(cb,^y3>z92PJM<>6[J\HZUvZGT1MsmUX4x㶔;Um ?d>
endstream
endobj
971 0 obj
910
endobj
674 0 obj
<<
/Type /Page
/Parent 668 0 R
/Resources << /ColorSpace << /CS2 935 0 R /CS3 939 0 R >> /ExtGState << /GS2 967 0 R /GS3 962 0 R >>
/Font << /TT2 937 0 R /TT3 934 0 R >> /ProcSet [ /PDF /Text ] >>
/Contents [ 941 0 R 943 0 R 945 0 R 947 0 R 949 0 R 951 0 R 953 0 R 955 0 R ]
/MediaBox [ 0 0 612 792 ]
/CropBox [ 0 0 612 792 ]
/Rotate 0
/StructParents 0
/Annots 675 0 R
>>
endobj
675 0 obj
[
676 0 R 678 0 R 680 0 R 682 0 R 684 0 R 686 0 R 688 0 R 690 0 R 692 0 R
694 0 R 696 0 R 698 0 R 700 0 R 702 0 R 704 0 R 706 0 R 708 0 R
710 0 R 712 0 R 714 0 R 716 0 R 718 0 R 720 0 R 722 0 R 724 0 R
726 0 R 728 0 R 730 0 R 732 0 R 734 0 R 736 0 R 738 0 R 740 0 R
742 0 R 744 0 R 746 0 R 748 0 R 750 0 R 752 0 R 754 0 R 756 0 R
758 0 R 760 0 R 762 0 R 764 0 R 766 0 R 768 0 R 770 0 R 772 0 R
774 0 R 776 0 R 778 0 R 780 0 R 782 0 R 784 0 R 786 0 R 788 0 R
790 0 R 792 0 R 794 0 R 796 0 R 798 0 R 800 0 R 802 0 R 804 0 R
806 0 R 808 0 R 810 0 R 812 0 R 814 0 R 816 0 R 818 0 R 820 0 R
822 0 R 824 0 R 826 0 R 828 0 R 830 0 R 832 0 R 834 0 R 836 0 R
838 0 R 840 0 R 842 0 R 844 0 R 846 0 R 848 0 R 850 0 R 852 0 R
854 0 R 856 0 R 858 0 R 860 0 R 862 0 R 864 0 R 866 0 R 868 0 R
870 0 R 872 0 R 874 0 R 876 0 R 878 0 R 880 0 R 882 0 R 884 0 R
886 0 R 888 0 R 890 0 R 892 0 R 894 0 R 896 0 R 898 0 R 900 0 R
902 0 R 904 0 R 906 0 R 908 0 R 910 0 R 912 0 R 914 0 R 916 0 R
918 0 R 920 0 R 922 0 R 924 0 R 926 0 R 928 0 R 930 0 R 932 0 R
]
endobj
676 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 681.87204 221.52176 702.12546 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE NAME)
/Ff 4096
/AP << /N 677 0 R >>
/V ()
/DA (/Helv 8 Tf 0 g)
/MaxLen 46
>>
endobj
677 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 196.83791 20.25342 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
678 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 349.37146 700.85962 358.23233 710.98633 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE GENDER CODE-M)
/Ff 49152
/AP << /N 679 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
679 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 8.86087 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
680 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 349.37146 690.73291 358.23233 700.85962 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE GENDER CODE-F)
/Ff 49152
/AP << /N 681 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
681 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 8.86087 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
682 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 411.39755 690.09999 431.65097 699.59378 ]
/F 4
/P 674 0 R
/FT /Tx
/T (AREA CODE)
/AP << /N 683 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 3
>>
endobj
683 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 20.25342 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
684 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 441.14476 690.09999 508.86713 699.59378 ]
/F 4
/P 674 0 R
/FT /Tx
/T (NUMBER)
/AP << /N 685 0 R >>
/MaxLen 8
/AA << /K 968 0 R /F 969 0 R >>
/DA (/Helv 10 Tf 0 g)
>>
endobj
685 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 67.72237 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
686 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 236.0789 688.20123 332.91556 700.85962 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE SSN)
/AP << /N 687 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 11
>>
endobj
687 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 96.83665 12.65839 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
688 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 25.94969 671.11241 310.13046 679.97328 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MAILING PRIMARY ADDRESS)
/AP << /N 689 0 R >>
/MaxLen 30
/DA (/Helv 8 Tf 0 g)
>>
endobj
689 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 284.18077 8.86087 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
690 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 25.94969 664.1503 310.13046 672.37825 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MAILING SECONDARY ADDRESS)
/AP << /N 691 0 R >>
/MaxLen 30
/DA (/Helv 8 Tf 0 g)
>>
endobj
691 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 284.18077 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
692 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 316.45966 656.55527 405.06836 678.07452 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MAILING CITY)
/Ff 4096
/AP << /N 693 0 R >>
/V ()
/DA (/Helv 7.5 Tf 0 g)
/MaxLen 20
>>
endobj
693 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 88.6087 21.51926 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
694 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 406.3342 664.1503 458.8665 676.80869 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MAILING STATE CODE)
/AP << /N 695 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 2
>>
endobj
695 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 52.5323 12.65839 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
696 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 460.76526 664.1503 553.17148 676.80869 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MAILING POSTAL CODE)
/AP << /N 697 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
/MaxLen 10
>>
endobj
697 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 92.40622 12.65839 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
698 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 28.48137 640.09937 46.83603 651.49191 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF BIRTH-MM)
/AP << /N 699 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
699 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 18.35466 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
700 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 50.63354 640.09937 67.08945 651.49191 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF BIRTH-DD)
/AP << /N 701 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
701 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 16.4559 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
702 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 71.51988 640.09937 97.46957 651.49191 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF BIRTH-YY)
/AP << /N 703 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
703 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 25.94969 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
704 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 108.2292 629.97266 120.25467 640.73228 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MARITAL STATUS CODE-1)
/Ff 49152
/AP << /N 705 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
705 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 12.02547 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
706 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 107.59628 640.73228 120.88759 651.49191 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MARITAL STATUS CODE-2)
/Ff 49152
/AP << /N 707 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
707 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 13.29131 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
708 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 161.39442 640.73228 174.68573 651.49191 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MARITAL STATUS CODE-3)
/Ff 49152
/AP << /N 709 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
709 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 13.29131 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
710 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 161.39442 629.97266 174.68573 640.73228 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE MARITAL STATUS CODE-4)
/Ff 49152
/AP << /N 711 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
711 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 13.29131 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
712 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 316.45966 623.64346 405.06836 652.75775 ]
/F 4
/P 674 0 R
/FT /Tx
/T (OCCUPATION DESCRIPTION)
/Ff 4096
/AP << /N 713 0 R >>
/V ()
/DA (/Helv 8 Tf 0 g)
>>
endobj
713 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 88.6087 29.11429 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
714 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 600.22545 274.05406 612.25092 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER NAME)
/AP << /N 715 0 R >>
/MaxLen 25
/DA (/Helv 10 Tf 0 g)
>>
endobj
715 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 249.37021 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
716 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 275.95282 600.22545 405.06836 612.25092 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER FEIN)
/AP << /N 717 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 9
>>
endobj
717 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 129.11554 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
718 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 408.86588 600.22545 432.91681 610.98508 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER AREA CODE)
/AP << /N 719 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
719 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 24.05093 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
720 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 437.34724 600.22545 484.81619 610.98508 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER NUMBER)
/AP << /N 721 0 R >>
/DA (/Helv 10 Tf 0 g)
/AA << /K 961 0 R /F 960 0 R >>
>>
endobj
721 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 47.46895 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
722 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 490.51247 600.22545 524.05719 610.98508 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER EXTENSION)
/AP << /N 723 0 R >>
/DA (/Helv 10 Tf 0 g)
>>
endobj
723 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 33.54472 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
724 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 582.50371 314.5609 590.73166 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER PHYSICAL PRIMARY ADDRESS)
/AP << /N 725 0 R >>
/MaxLen 30
/DA (/Helv 8 Tf 0 g)
>>
endobj
725 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 289.87704 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
726 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 576.80743 314.5609 584.40247 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER PHYSICAL SECONDARY ADDRESS)
/AP << /N 727 0 R >>
/MaxLen 30
/DA (/Helv 8 Tf 0 g)
>>
endobj
727 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 289.87704 7.59503 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
728 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 316.45966 571.11116 405.06836 590.73166 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER PHYSICAL CITY)
/Ff 4096
/AP << /N 729 0 R >>
/V ()
/DA (/Helv 8 Tf 0 g)
/MaxLen 20
>>
endobj
729 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 88.6087 19.6205 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
730 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 406.3342 577.44035 458.8665 589.46582 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER PHYSICAL STATE CODE)
/AP << /N 731 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 2
>>
endobj
731 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 52.5323 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
732 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 460.76526 577.44035 552.53856 589.46582 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER PHYSICAL POSTAL CODE)
/AP << /N 733 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
/MaxLen 10
>>
endobj
733 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 91.7733 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
734 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 72.78572 547.69315 151.26772 555.9211 ]
/F 4
/P 674 0 R
/FT /Tx
/T (AVERAGE WEEKLY WAGE AT TIME OF INJURY)
/AP << /N 735 0 R >>
/MaxLen 12
/AA << /K 956 0 R /F 959 0 R >>
/DA (/Helv 9 Tf 0 g)
>>
endobj
735 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 78.48199 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
736 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 152.53355 547.69315 162.66026 557.18694 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE TIP-Y)
/AP << /N 737 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
737 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
738 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 196.83791 547.06023 206.3317 557.81985 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE MEALS-Y)
/AP << /N 739 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
739 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
740 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 152.53355 535.66768 162.66026 546.42731 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE ROOM/LODGING-Y)
/AP << /N 741 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
741 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
742 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 196.83791 536.3006 206.3317 546.42731 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE HEALTH INSURANCE-Y)
/AP << /N 743 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
743 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
744 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 406.3342 641.3652 417.09383 651.49191 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYMENT STATUS CODE-1)
/AP << /N 745 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
745 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
746 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 467.09445 641.3652 477.85408 651.49191 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYMENT STATUS CODE-2)
/AP << /N 747 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
747 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
748 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 469.84407 40.50684 483.13538 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DATE OF INJURY-MM)
/AP << /N 749 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
>>
endobj
749 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 15.82298 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
750 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 40.50684 469.84407 55.6969 483.13538 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DATE OF INJURY-DD)
/AP << /N 751 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
>>
endobj
751 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 15.19006 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
752 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 56.96274 469.84407 79.74783 483.13538 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DATE OF INJURY-YY)
/AP << /N 753 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
>>
endobj
753 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 22.7851 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
754 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 200.0025 470.47699 210.12921 481.23662 ]
/F 4
/P 674 0 R
/FT /Tx
/T (TIME OF INJURY-MERIDIAN-AM)
/Ff 49152
/AP << /N 755 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
755 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
756 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 200.0025 460.9832 210.12921 471.10991 ]
/F 4
/P 674 0 R
/FT /Tx
/T (TIME OF INJURY-MERIDIAN-PM)
/Ff 49152
/AP << /N 757 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
757 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
758 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 245.57269 469.21115 262.66151 482.50246 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL DATE LAST DAY WORKED-MM)
/AP << /N 759 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 2
>>
endobj
759 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 17.08882 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
760 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 265.82611 469.21115 282.28201 482.50246 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL DATE LAST DAY WORKED-DD)
/AP << /N 761 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
761 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 16.4559 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
762 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 286.71245 469.21115 312.02922 482.50246 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL DATE LAST DAY WORKED-YY)
/AP << /N 763 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
763 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 25.31677 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
764 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 339.24475 469.21115 356.33357 482.50246 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DATE EMPLOYER HAD KNOWLEDGE OF THE INJURY-MM)
/AP << /N 765 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
765 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 17.08882 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
766 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 359.49817 469.21115 376.58699 482.50246 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DATE EMPLOYER HAD KNOWLEDGE OF THE INJURY-DD)
/AP << /N 767 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
767 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 17.08882 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
768 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 379.11867 469.21115 405.70128 482.50246 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DATE EMPLOYER HAD KNOWLEDGE OF THE INJURY-YY)
/AP << /N 769 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
769 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 26.58261 13.29131 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
770 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 167.72362 472.37575 196.20499 483.13538 ]
/F 4
/P 674 0 R
/FT /Tx
/T (TIME OF INJURY-TIMEAM)
/AP << /N 771 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
>>
endobj
771 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 28.48137 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
772 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 167.72362 462.24904 196.20499 471.74283 ]
/F 4
/P 674 0 R
/FT /Tx
/T (TIME OF INJURY-TIMEPM)
/AP << /N 773 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
>>
endobj
773 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 28.48137 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
774 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 428.48637 469.84407 443.04352 481.23662 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL DATE DISABILITY BEGAN-MM)
/AP << /N 775 0 R >>
/Q 2
/DA (/Helv 10 Tf 0 g)
>>
endobj
775 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 14.55714 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
776 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 446.20811 469.84407 463.92986 481.23662 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL DATE DISABILITY BEGAN-DD)
/AP << /N 777 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
777 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 17.72174 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
778 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 467.09445 469.84407 490.51247 481.23662 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL DATE DISABILITY BEGAN-YY)
/AP << /N 779 0 R >>
/DA (/Helv 10 Tf 0 g)
>>
endobj
779 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 23.41801 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
780 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 557.60191 469.84407 582.91869 481.23662 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL RETURN TO WORK DATE-YY)
/AP << /N 781 0 R >>
/DA (/Helv 10 Tf 0 g)
>>
endobj
781 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 25.31677 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
782 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 537.3485 469.84407 553.8044 481.23662 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL RETURN TO WORK DATE-DD)
/AP << /N 783 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
783 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 16.4559 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
784 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 518.36092 469.84407 534.1839 481.23662 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL RETURN TO WORK DATE-MM)
/AP << /N 785 0 R >>
/Q 2
/DA (/Helv 10 Tf 0 g)
>>
endobj
785 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 15.82298 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
786 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 127.21678 469.21115 136.71057 480.6037 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE BEGAN WORK TIME-MERIDIAN-AM)
/Ff 49152
/AP << /N 787 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
787 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
788 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 127.21678 457.8186 136.71057 467.94531 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE BEGAN WORK TIME-MERIDIAN-PM)
/Ff 49152
/AP << /N 789 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
789 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
790 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 89.24162 471.74283 117.72299 481.86954 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE BEGAN WORK TIME-TIMEAM)
/AP << /N 791 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
>>
endobj
791 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 28.48137 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
792 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 89.24162 459.08444 117.72299 469.21115 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE BEGAN WORK TIME-TIMEPM)
/AP << /N 793 0 R >>
/Q 1
/DA (/Helv 9 Tf 0 g)
/MaxLen 5
>>
endobj
793 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 28.48137 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
794 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 26.58261 412.24841 36.70932 422.37512 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DEATH RESULT OF INJURY CODE-Y)
/AP << /N 795 0 R >>
/MaxLen 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
795 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
796 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 64.55777 412.24841 74.68448 422.37512 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DEATH RESULT OF INJURY CODE-N)
/AP << /N 797 0 R >>
/MaxLen 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
797 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
798 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 105.69753 405.91922 122.15343 417.94469 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF DEATH-MM)
/AP << /N 799 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
799 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 16.4559 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
800 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 124.6851 405.91922 139.87517 417.94469 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF DEATH-DD)
/AP << /N 801 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
801 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 15.19006 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
802 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 142.40685 405.91922 171.52113 417.94469 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF DEATH-YY)
/AP << /N 803 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
803 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 29.11429 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
804 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 482.91743 427.43848 491.77831 436.29935 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INTOXICATION-Y)
/Ff 49152
/AP << /N 805 0 R >>
/MaxLen 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
805 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 8.86087 8.86087 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
806 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 482.91743 417.31177 491.77831 426.17264 ]
/F 4
/P 674 0 R
/FT /Tx
/T (FAILURE TO USE SAFETY DEVICES-Y)
/Ff 49152
/AP << /N 807 0 R >>
/MaxLen 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
807 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 8.86087 8.86087 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
808 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 25.94969 506.55339 36.70932 516.04718 ]
/F 4
/P 674 0 R
/FT /Tx
/T (SELF INSURED-Y)
/Ff 49152
/AP << /N 809 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
809 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
810 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 75.95032 506.55339 86.70995 516.04718 ]
/F 4
/P 674 0 R
/FT /Tx
/T (SELF INSURED-N)
/Ff 49152
/AP << /N 811 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
811 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
812 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 173.41989 429.97015 439.246 437.56519 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DEPENDENT NAME)
/AP << /N 813 0 R >>
/Q 0
/DA (/Helv 7 Tf 0 g)
>>
endobj
813 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 265.82611 7.59503 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
814 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 173.41989 421.7422 285.44661 429.97015 ]
/F 4
/P 674 0 R
/FT /Tx
/T (DEPENDENT RELATIONSHIP)
/AP << /N 815 0 R >>
/DA (/Helv 7 Tf 0 g)
>>
endobj
815 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 112.02672 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
816 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 173.41989 414.14717 373.42239 423.00804 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DEPENDENT PRIMARY ADDRESS)
/AP << /N 817 0 R >>
/DA (/Helv 7 Tf 0 g)
>>
endobj
817 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 200.0025 8.86087 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
818 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 173.41989 407.18506 373.42239 415.41301 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DEPENDENT SECONDARY ADDRESS)
/AP << /N 819 0 R >>
/DA (/Helv 7 Tf 0 g)
>>
endobj
819 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 200.0025 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
820 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 173.41989 400.22295 481.6516 407.81798 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DEPENDENT CITY STATE ZIP)
/AP << /N 821 0 R >>
/DA (/Helv 7 Tf 0 g)
>>
endobj
821 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 308.2317 7.59503 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
822 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 298.105 376.17201 589.24788 388.19748 ]
/F 4
/P 674 0 R
/FT /Tx
/T (NATURE OF INJURY CODE-DESCRIPTION)
/Ff 4096
/AP << /N 823 0 R >>
/V ()
/DA (/Helv 9 Tf 0 g)
/MaxLen 75
>>
endobj
823 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 291.14288 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
824 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 376.17201 296.83916 388.19748 ]
/F 4
/P 674 0 R
/FT /Tx
/T (PART OF BODY INJURED CODE-DESCRIPTION)
/Ff 4096
/AP << /N 825 0 R >>
/V ()
/DA (/Helv 9 Tf 0 g)
/MaxLen 75
>>
endobj
825 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 272.1553 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
826 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 298.105 293.8925 589.24788 330.60182 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EQUIPMENT USED DURING OCCURRENCE)
/Ff 4096
/AP << /N 827 0 R >>
/V ()
/DA (/Helv 9 Tf 0 g)
/MaxLen 50
>>
endobj
827 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 291.14288 36.70932 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
828 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 350.22232 589.24788 364.14655 ]
/F 4
/P 674 0 R
/FT /Tx
/T (SPECIFIC ACTIVITY ENGAGED IN DURING OCCURRENCE)
/AP << /N 829 0 R >>
/MaxLen 40
/DA (/Helv 10 Tf 0 g)
>>
endobj
829 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 564.56403 13.92422 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
830 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 293.25958 296.83916 330.60182 ]
/F 4
/P 674 0 R
/FT /Tx
/T (ACCIDENT/INJURY DESCRIPTION NARRATIVE)
/Ff 4096
/AP << /N 831 0 R >>
/V ()
/DA (/Helv 9 Tf 0 g)
/MaxLen 100
>>
endobj
831 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 272.1553 37.34224 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
832 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 27.84845 258.44902 36.0764 267.30989 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INJURY/ILLNESS EXPOSURE ON EMPLOYER PREMISES-Y)
/Ff 49152
/AP << /N 833 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
833 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 8.22795 8.86087 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
834 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 63.92485 258.44902 72.1528 267.30989 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INJURY/ILLNESS EXPOSURE ON EMPLOYER PREMISES-N)
/Ff 49152
/AP << /N 835 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
835 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 8.22795 8.86087 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
836 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 241.14226 638.20061 257.59816 649.59315 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF HIRE-MM)
/AP << /N 837 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 10
>>
endobj
837 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 16.4559 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
838 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 281.64909 638.20061 303.80127 649.59315 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF HIRE-YY)
/AP << /N 839 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 10
>>
endobj
839 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 22.15218 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
840 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 261.39568 638.20061 278.4845 649.59315 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE DATE OF HIRE-DD)
/AP << /N 841 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 10
>>
endobj
841 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 17.08882 11.39255 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
842 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 153.16647 506.55339 162.66026 516.04718 ]
/F 4
/P 674 0 R
/FT /Tx
/T (FULL WAGES PAID FOR DATE OF INJURY INDICATOR-Y)
/Ff 49152
/AP << /N 843 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
843 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
844 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 191.14163 506.55339 200.63542 516.04718 ]
/F 4
/P 674 0 R
/FT /Tx
/T (FULL WAGES PAID FOR DATE OF INJURY INDICATOR-N)
/Ff 49152
/AP << /N 845 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
845 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
846 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 89.87454 267.30989 234.18015 286.29747 ]
/F 4
/P 674 0 R
/FT /Tx
/T (ACCIDENT SITE LOCATION NARRATIVE)
/Ff 4096
/AP << /N 847 0 R >>
/V ()
/DA (/Helv 8 Tf 0 g)
>>
endobj
847 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 144.3056 18.98758 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
848 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 89.87454 247.68939 234.18015 267.30989 ]
/F 4
/P 674 0 R
/FT /Tx
/T (ACCIDENT SITE STREET)
/Ff 4096
/AP << /N 849 0 R >>
/V ()
/DA (/Helv 8 Tf 0 g)
>>
endobj
849 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 144.3056 19.6205 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
850 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 89.87454 219.20802 234.18015 248.32231 ]
/F 4
/P 674 0 R
/FT /Tx
/T (ACCIDENT SITE CITY STATE ZIP)
/Ff 4096
/AP << /N 851 0 R >>
/V ()
/DA (/Helv 8 Tf 0 g)
>>
endobj
851 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 144.3056 29.11429 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
852 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 236.0789 258.44902 245.57269 267.94281 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL TREATMENT CODE-0)
/Ff 49152
/AP << /N 853 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
853 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
854 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 236.0789 248.32231 245.57269 257.18318 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL TREATMENT CODE-1)
/Ff 49152
/AP << /N 855 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
855 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 8.86087 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
856 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 236.0789 238.1956 245.57269 246.42355 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL TREATMENT CODE-2)
/Ff 49152
/AP << /N 857 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
857 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
858 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 312.02922 258.44902 322.15593 267.94281 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL TREATMENT CODE-3)
/Ff 49152
/AP << /N 859 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
859 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
860 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 312.02922 248.32231 321.52301 257.8161 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL TREATMENT CODE-4)
/Ff 49152
/AP << /N 861 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
861 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
862 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 212.24591 282.91493 221.7397 ]
/F 4
/P 674 0 R
/FT /Tx
/T (WITNESS NAME)
/AP << /N 863 0 R >>
/DA (/Helv 8 Tf 0 g)
>>
endobj
863 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 258.23108 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
864 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 205.91672 282.91493 215.41051 ]
/F 4
/P 674 0 R
/FT /Tx
/T (WITNESS SECOND NAME)
/AP << /N 865 0 R >>
/DA (/Helv 8 Tf 0 g)
>>
endobj
865 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 258.23108 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
866 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 298.105 201.48628 578.48825 219.84094 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYER REPRESENTATIVE NOTIFIED NAM)
/Ff 4096
/AP << /N 867 0 R >>
/V ()
/DA (/Helv 9 Tf 0 g)
/MaxLen 46
>>
endobj
867 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 280.38326 18.35466 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
868 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.05093 191.99249 296.83916 198.95461 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL MEDICAL PROVIDER NAME)
/Ff 4096
/DA (/Helv 6 Tf 0 g)
/V ()
/AP << /N 869 0 R >>
>>
endobj
869 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 272.78822 6.96211 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
870 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.05093 185.6633 174.05281 193.25833 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL MEDICAL PROVIDER PHYSICAL PRIMARY ADDRESS)
/DA (/Helv 6 Tf 0 g)
/AP << /N 871 0 R >>
>>
endobj
871 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 150.00188 7.59503 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
872 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 174.68573 185.6633 296.83916 192.62541 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL MEDICAL PROVIDER PHYSICAL SECONDARY ADDRESS)
/DA (/Helv 6 Tf 0 g)
/AP << /N 873 0 R >>
>>
endobj
873 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 122.15343 6.96211 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
874 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.05093 181.86578 296.83916 188.8279 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INITIAL MEDICAL PROVIDER PHYSICAL CITY STATE ZIP)
/Ff 4096
/DA (/Helv 6 Tf 0 g)
/V ()
/AP << /N 875 0 R >>
>>
endobj
875 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 272.78822 6.96211 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
876 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 298.105 193.25833 589.24788 198.95461 ]
/F 4
/P 674 0 R
/FT /Tx
/T (HOSPITAL NAME)
/Ff 4096
/DA (/Helv 6 Tf 0 g)
/V 957 0 R
/AP << /N 877 0 R >>
>>
endobj
877 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 291.14288 5.69627 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
878 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 298.105 186.29622 443.67644 193.25833 ]
/F 4
/P 674 0 R
/FT /Tx
/T (HOSPITAL PHYSICAL PRIMARY ADDRESS)
/DA (/Helv 6 Tf 0 g)
/AP << /N 879 0 R >>
>>
endobj
879 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 145.57144 6.96211 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
880 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 443.67644 185.6633 589.24788 192.62541 ]
/F 4
/P 674 0 R
/FT /Tx
/T (HOSPITAL PHYSICAL SECONDARY ADDRESS)
/DA (/Helv 6 Tf 0 g)
/AP << /N 881 0 R >>
>>
endobj
881 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 145.57144 6.96211 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
882 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 298.105 181.86578 589.24788 188.8279 ]
/F 4
/P 674 0 R
/FT /Tx
/T (HOSPITAL PHYSICAL CITY STATE ZIP)
/Ff 4096
/DA (/Helv 6 Tf 0 g)
/V ()
/AP << /N 883 0 R >>
>>
endobj
883 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 291.14288 6.96211 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
884 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.05093 152.11858 206.96461 171.10616 ]
/F 4
/P 674 0 R
/FT /Tx
/T (PREPARER NAME)
/Ff 4096
/DA (/Helv 8 Tf 0 g)
/V ()
/AP << /N 885 0 R >>
/MaxLen 46
>>
endobj
885 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 182.91368 18.98758 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
886 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 206.96461 157.18193 340.51059 171.10616 ]
/F 4
/P 674 0 R
/FT /Tx
/T (PREPARER TITLE)
/Ff 4096
/AP << /N 887 0 R >>
/V ()
/DA (/Helv 9 Tf 0 g)
/MaxLen 20
>>
endobj
887 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 133.54597 13.92422 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
888 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 472.79073 157.18193 496.84166 169.2074 ]
/F 4
/P 674 0 R
/AP << /N 889 0 R >>
/Parent 14 0 R
>>
endobj
889 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 24.05093 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
890 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 345.57394 159.71361 371.52364 169.84032 ]
/F 4
/P 674 0 R
/FT /Tx
/T (PREPARERS AREA CODE)
/AP << /N 891 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 3
>>
endobj
891 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 25.94969 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
892 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 375.32115 159.71361 443.67644 169.84032 ]
/F 4
/P 674 0 R
/FT /Tx
/T (PREPARERS PHONE NUMBER)
/AP << /N 893 0 R >>
/MaxLen 8
/AA << /K 966 0 R /F 958 0 R >>
/DA (/Helv 10 Tf 0 g)
>>
endobj
893 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 68.35529 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
894 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 500.00626 157.18193 517.09508 169.2074 ]
/F 4
/P 674 0 R
/AP << /N 895 0 R >>
/Parent 15 0 R
>>
endobj
895 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 17.08882 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
896 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 520.25967 157.18193 554.43732 169.2074 ]
/F 4
/P 674 0 R
/AP << /N 897 0 R >>
/Parent 16 0 R
>>
endobj
897 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 34.17764 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
898 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 460.13234 258.44902 470.89197 267.94281 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE HOSPITALISED OVERNIGHT INDICATOR-N)
/AP << /N 899 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
899 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
900 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 420.25842 258.44902 431.01805 267.94281 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE HOSPITALISED OVERNIGHT INDICATOR-Y)
/AP << /N 901 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
>>
endobj
901 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
902 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 104.64963 296.83916 121.73845 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INSURER NAME)
/Ff 4096
/AP << /N 903 0 R >>
/V ()
/DA (/Helv 9 Tf 0 g)
/MaxLen 40
>>
endobj
903 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 272.1553 17.08882 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
904 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 329.75096 122.37137 589.24788 130.59932 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INSURER MAILING PRIMARY ADDRESS)
/DA (/Helv 8 Tf 0 g)
/AP << /N 905 0 R >>
>>
endobj
905 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 259.49692 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
906 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 329.75096 115.40926 589.24788 123.63721 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INSURER MAILING SECONDARY ADDRESS)
/AP << /N 907 0 R >>
/DA (/Helv 8 Tf 0 g)
>>
endobj
907 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 259.49692 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
908 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 329.75096 107.81422 589.24788 116.04218 ]
/F 4
/P 674 0 R
/FT /Tx
/T (INSURER MAILING CITY STATE ZIP)
/DA (/Helv 8 Tf 0 g)
/AP << /N 909 0 R >>
>>
endobj
909 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 259.49692 8.22795 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
910 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 24.68385 43.25645 137.34349 55.28192 ]
/F 4
/P 674 0 R
/FT /Tx
/T (POLICY/CONTRACT NUMBER)
/AP << /N 911 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 9
>>
endobj
911 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 112.65964 12.02547 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
912 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 331.64972 43.25645 350.6373 54.01608 ]
/F 4
/P 674 0 R
/DA (/Helv 10 Tf 0 g)
/Q 1
/AP << /N 913 0 R >>
/Parent 14 0 R
>>
endobj
913 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 18.98758 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
914 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 353.8019 43.25645 371.52364 54.01608 ]
/F 4
/P 674 0 R
/DA (/Helv 10 Tf 0 g)
/Q 1
/AP << /N 915 0 R >>
/Parent 15 0 R
>>
endobj
915 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 17.72174 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
916 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 374.05531 43.25645 406.96712 54.01608 ]
/F 4
/P 674 0 R
/DA (/Helv 10 Tf 0 g)
/Q 1
/AP << /N 917 0 R >>
/Parent 16 0 R
>>
endobj
917 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 32.9118 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
918 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 406.3342 630.60558 417.09383 640.73228 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYMENT STATUS CODE-9)
/AP << /N 919 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
919 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
920 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 465.82861 630.60558 476.58824 640.73228 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYMENT STATUS CODE-U)
/AP << /N 921 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
921 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.75963 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
922 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 317.09258 506.55339 327.21928 516.04718 ]
/F 4
/P 674 0 R
/FT /Tx
/T (WAGES CONTINUED PER CRS-Y)
/Ff 49152
/AP << /N 923 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
923 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
924 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 364.56152 506.55339 374.68823 516.04718 ]
/F 4
/P 674 0 R
/FT /Tx
/T (WAGES CONTINUED PER CRS-N)
/Ff 49152
/AP << /N 925 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
925 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 9.49379 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
926 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 317.09258 545.79439 327.21928 555.9211 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE TIP AS AWW-Y)
/AP << /N 927 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
927 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
928 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 317.09258 533.136 327.21928 543.89563 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE ROOM AS AWW-Y)
/AP << /N 929 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
929 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 10.12671 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
930 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 424.68886 545.16147 434.18265 555.9211 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE MEALS AS AWW-Y)
/AP << /N 931 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
931 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 10.75963 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
932 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 424.68886 533.76892 434.18265 543.89563 ]
/F 4
/P 674 0 R
/FT /Tx
/T (EMPLOYEE RECEIVE HEALTH INSURANCE AS AWW-Y)
/AP << /N 933 0 R >>
/Q 1
/DA (/Helv 10 Tf 0 g)
/MaxLen 1
>>
endobj
933 0 obj
<< /Length 11 /Subtype /Form /BBox [ 0 0 9.49379 10.12671 ] /Resources << /ProcSet [ /PDF ] >> >>
stream
/Tx BMC EMC
endstream
endobj
934 0 obj
<<
/Type /Font
/Subtype /TrueType
/FirstChar 32
/LastChar 146
/Widths [ 278 0 474 0 0 0 722 238 333 333 0 0 278 333 278 0 556 556 556 556
556 556 556 0 556 0 333 0 0 0 0 0 0 722 0 722 722 667 611 778 722
278 556 0 611 833 722 778 667 0 722 667 611 722 0 944 0 667 0 0
0 0 0 0 0 556 611 556 611 556 333 611 611 278 278 556 278 889 611
611 611 611 389 556 333 611 556 778 0 556 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 278 ]
/Encoding /WinAnsiEncoding
/BaseFont /HHBKBG+Arial,Bold
/FontDescriptor 936 0 R
>>
endobj
935 0 obj
[
/ICCBased 963 0 R
]
endobj
936 0 obj
<<
/Type /FontDescriptor
/Ascent 905
/CapHeight 718
/Descent -211
/Flags 32
/FontBBox [ -628 -376 2034 1010 ]
/FontName /HHBKBG+Arial,Bold
/ItalicAngle 0
/StemV 144
/FontFile2 964 0 R
>>
endobj
937 0 obj
<<
/Type /Font
/Subtype /TrueType
/FirstChar 32
/LastChar 146
/Widths [ 278 0 355 556 556 0 0 191 333 333 0 0 278 333 278 278 556 556 556
556 556 556 556 0 556 556 278 278 0 0 584 556 0 667 667 722 722
667 611 0 722 278 0 667 556 833 722 778 667 0 722 667 611 722 667
944 0 667 611 0 0 0 0 0 0 556 556 500 556 556 278 556 556 222 222
500 222 833 556 556 556 556 333 500 278 556 500 722 500 500 500
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 222 ]
/Encoding /WinAnsiEncoding
/BaseFont /HHBKEA+Arial
/FontDescriptor 938 0 R
>>
endobj
938 0 obj
<<
/Type /FontDescriptor
/Ascent 905
/CapHeight 718
/Descent -211
/Flags 32
/FontBBox [ -665 -325 2028 1006 ]
/FontName /HHBKEA+Arial
/ItalicAngle 0
/StemV 94
/XHeight 515
/FontFile2 965 0 R
>>
endobj
939 0 obj
/DeviceGray
endobj
940 0 obj
1372
endobj
941 0 obj
<< /Filter /FlateDecode /Length 940 0 R >>
stream
HW[oG~_q>ԑa#E0֩6J>PXqq].0y-5͙m~>|vV'0Y֓E 5*fM,gU9/6r2iO:OZyAPB)M!{+Wr0R!'WYQ@XoV&rXrKҴH.S߶8bV崀2Uuz6ݚۂI`c[Ng|_}xҔU'ifljIA7+6 Ҁg0Ú0%nD`!X94yfHs
G(9o}=A{Ѕ^nQ@0:V0$`:U9J6UfÁKpKoa7ڹ1V}ȓq<\xRk5n*O[7#$Mkjzy7,Q~8|m+b̕ ;\M2y$L0e%㵌)Ed%O}J-ftf4E8
>2S}C@(rleYZkz
ry9Ί07o"=B%F%I9~l9)3ȊɷU $ɕ!3~s4Nԝ01['C,jd;:u2/G/
S@oyR?,ۂH}*WR<+U*mYʜ1E(m9Qۢnxvzﺔ[p
eU9>MYRC" U&t]x]^ٚ^6N3U "F3)z <\A2
ld@$V =(,01'\L &4 Ҝ`YmYn<@f5 7H6ZLJjZGl6uSAB3
qșCccę
>PT?E+$CbwHw[p`lĪGNfEl9gm4ƞ_KYi2Wk7(60NWz3r1
d`3L]CN.]:5c\FT#;;*VIrOmRå$e2!5A|g#iC-@mDhjm5;{j/5t!-IRT
5G*_