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Notice Regarding Workers' Compensation Claim (180 Days) WC-003 - California
|Notice Regarding Workers' Compensation Claim (180 Days) Form. This is a California form and can be used in General Workers Comp .||
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NOTICE REGARDING WORKERS' COMPENSATION CLAIM Employee Name: Date of Injury: Employer Name: Claims Administrator: Telephone No.: Claim Number: YOUR CLAIM HAS BEEN INACTIVE FOR AT LEAST THE PREVIOUS 180 DAYS. YOUR CLAIM WILL BE DISMISSED BY THE OPERATION OF LAW PURSUANT TO LABOR CODE SECTION 5404.5, WITHOUT FURTHER NOTICE, UNLESS YOU FILE AN APPLICATION FOR ADJUDICATION OF CLAIM WITH THE WORKERS' COMPENSATION APPEALS BOARD WITHIN 180 DAYS OF THE DATE OF SERVICE OF THIS NOTICE. Your claim(s) on the attached claim form(s) will be dismissed by operation of law if you do not file an application for adjudication of claim with the workers' compensation appeals board within 180 days of , which is the date of service of this notice. You may contact the Division of Workers' Compensation at telephone number 1-800-736-7401 for information about your workers' compensation claim. You may also consult an attorney. WC-003 2002 © American LegalNet, Inc.