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Fill and Sign the Wcab Ca Form 10214 E Ver1 9 08 08 Dir

Fill and Sign the Wcab Ca Form 10214 E Ver1 9 08 08 Dir

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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF W ORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD Case No. Applicant VS. Defendants Petition for Appointment of Guardian ad Litem and Trustee As a result of an alleged industrial injury on, to Injured Employee while employed by Employer benefits are claimed by the following minor(s)/incompetent(s): Strike inapplicable matter NameDate of Birth The minor(s)/incompetent(s) require a Guardian ad Litem and Trustee to prosecute the claim and to receive Strike inapplicable matter and receipt for any benefits awarded or voluntarily furnished. The W orkers' Compensation Appeals Board is requested to appoint Relationship if any ,, as Guardian ad Litem and Trustee. * who has legal custody of, and is legally responsible for the support of the minor(s). ( * Strike if not applicable.) W e hereby join in the above request. NOTE: Consent must be signed by all minors over 14 years of age and by all adults with sufficient capacity to form an intelligent preference. Date , Petitioner Address Attorney for Petitioner Address and telephone number DIA W CAB FORM 8 (REV. 10-90)WCAB-8

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