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Petition For Benefits And Or Penalty WC-100 - California
| Petition For Benefits And Or Penalty Form. This is a California form and can be used in General Workers Comp . |
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Attorney for Petitioner STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD FOR WCAB USE ONLY (PRINT OR TYPE NAMES AND ADDRESSES) Name of Injured Workers WCAB CASE NUMBER (IF APPLICATION HAS BEEN FILED) Date of Claimed Injury Address PETITION FOR Benefits Under Labor Code section 132a Benefits Under Labor Code section 4553 Penalty Under Labor Code section 5814 Other Social Security Number Name of Employer Address Name of Insurance Carrier/Adjusting Agency Address Petitioner Address worker other employer carrier PETITIONER ALLEGES AS FOLLOWS: 2002 © American LegalNet, Inc. (PROOF OF SERVICE MUST BE ATTACHED) WC-100
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