California > Workers Comp > General

Pre-Trial Conference Statement Lien Issues Addendum WCAB 24.1 - California

Pre-Trial Conference Statement Lien Issues Addendum Form. This is a California form and can be used in General Workers Comp .
 Fillable pdf Last Modified 2/11/2014
Get this form for FREE as a print-only pdf

STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT LIEN ISSUES ADDENDUM (TO BE COMPLETED BY DEFENDANT AND LIEN CLAIMANT-ONE ADDENDUM PAGE FOR EACH LIEN) Case # ADJ LIEN CLAIMANT BALANCE LIEN CLAIMANTS TREATMENT EXPENSE ENTITLEMENT MEDICAL LEGAL EXPENSE ENTITLEMENT INTERPRETING EXPENSE ENTITLEMENT 15% INCREASE/INTEREST (L.C. 4603.2(b)(2)) (treatment) PENALTIES AND INTEREST (L.C. 4622) (med legal) DEFENDANT WHETHER REASONABLY REQUIRED (NECESSITY) Appeal of IMR ____________ Fraud ____________ Conflict of Interest ____________ Mistake of Fact REASONABLENESS/VALUE OF CHARGES Appeal of IBR Determination ____________ Fraud ____________ Conflict of Interest ____________ Mistake of Fact TREATMENT OUTSIDE MPN 24 VISIT CAP NO CONTESTED CLAIM (MED LEGAL) CERTIFICATION AOE/COE BODY PARTS STATUTE OF LIMITATIONS LACHES ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ OTHER (either party)___________________________________________________________________ Lien Claimant________________________________ WCAB Form 24.1 (Revised 2013) American LegalNet, Inc. Defendant______________________________
Link/Embed this Document

Popular Searches

  1. bill of costs
  2. Request for entry of default
  3. Preliminary Change of Ownership Report
  4. stipulation of discontinuance
  5. Notice and Acknowledgment of Receipt
  6. proof of service of summons
  7. Decree of Dissolution of Marriage
  8. Petition to Expunge
  9. writ of replevin
  10. fee waiver

Bookmark and Share