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* 1. Employee Name

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* 2. Employee ID Number

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* 3. Claim Number

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* 4. Did Claims Adjuster clearly explain benefits to you?

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* 5. Was Claims Adjuster prompt/responsive to your questions?

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* 6. Was Claims Adjuster helpful?

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* 7. Did Claims Adjuster resolve your concerns?

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* 8. Were your medical care needs met?

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* 9. How would you rate your overall experience/interaction with the Workers' Compensation Division?

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* 10. Please share any additional comments/suggestions to help us better serve you.

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* 11. If you wish to be contacted, please provide your phone number.

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