Fill and Sign the California Workers Compensation Form

                                                                                                                      sum of       Dollars ($       The reasonable expense incurred by or on behalf of said worker for medical treatment to cure or relieve from the The reasonable medical expense incurred to prove a contested claim; or The reasonable value of living expenses of said worker or of his or her dependents, subsequent to the injury, or The reasonable living expenses of the spouse or minor children, or both, of said worker, subsequent to the date of The reasonable fee for interpreter's services performed on             a copy of the original completed Employee's Claim for Workers' Compensation Benefits (DWC Form 1) is attached, or the lien claimant does not have a copy of the claim form, but made the following efforts to secure one: A copy of the lien claim and supporting documents was served by mail or delivered to each of the above-named parties.       STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD NOTICE AND REQUEST FOR ALLOWANCE OF LIEN(Print or type names and addresses; include ZIP Codes) ID OR CASE NO. Injured Worker Address Date of Claimed Injury Social Security Number Date of Birth Attorney for Injured Worker Address Employer Address Insurance Carrier or, if Self-Insured, Certificate Name Address Where Claim Administered Adjusting Agency, if Agency Administered Attorney for Employer/Carrier Address Lien Claimant Address and Telephone No. Attorney for Lien Claimant Address and Telephone No. The lien claimant hereby requests the Workers' Compensation Appeals Board to determine and allow as a lien the ) against any amount now due or which may hereafter become payable as compensation to the above named worker on account of the above claimed injury. This request and claim for lien is for (Mark appropriate box): effects of said injury; or injury, where such worker has deserted or is neglecting his or her family; or20 NOTE: ITEMIZED STATEMENT JUSTIFYING THE LIEN MUST BE ATTACHED FOR INJURIES OCCURRING ON OR AFTER JANUARY 1, 1990, FOR WHICH THE LIEN CLAIMANT DOES NOT HAVE A WCAB IDENTIFICATION NUMBER, the lien claimant declares under penalty of perjury that: Signature of Attorney for Lien Claimant Signature of Lien Claimant Date EMPLOYEE'S CONSENT TO ALLOWANCE OF LIEN I consent to the requested allowance o a lien against my compensation. Signature of Attorney for Injured Worker Signature of Injured Worker DWC WCAB Form 6 (Rev 2/91)