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Description of form 25r
Distance Near HEARING Scale used Percentage of loss Right ear PLEASE ATTACH AUDIOGRAMS AND CALCULATIONS OF HEARING LOSS OTHER Permanent injury to or impairment of any other organ or part of body identify Disfigurement Location face head FORM 25R 8/1/08 PAGE 1 OF 2 Left ear body SELF-INSURED EMPLOYER OR CARRIER MAIL TO NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH NORTH CAROLINA 27699-4335 MAIN TELEPHONE...
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