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2. CASE STATUS Check and complete, as appropriate:
5. ISSUES REMAINING FOR DETERMINATION Check all issues that remain:
6. List the lay witnesses you intend to call in your case-in-chief:
7. List the expert witnesses you intend to call in your case-in-chief:
I hereby certify that I mailed or delivered the original Case Information Sheet (CIS) to all parties at the addresses shown below (A claimant must provide a copy to the employer and the insurer, or their attorney):
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