California > Workers Comp > EAMS Forms
Notice And Request For Allowance Of Lien DWC-WCAB 6 - California
| Notice And Request For Allowance Of Lien Form. This is a California form and can be used in EAMS Forms Workers Comp . |
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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD NOTICE AND REQUEST FOR ALLOWANCE OF LIEN Date Of Original Lien: MM/DD/YYYY Original Lien Amended Lien Case No. (Choose only one) a specific injury on (DATE OF INJURY: MM/DD/YYYY) a cumulative injury which began on (START DATE: MM/DD/YYYY) and ended on (END DATE: MM/DD/YYYY) SSN (Numbers Only) Injured Worker: First Name Last Name Address/PO Box ( Please leave blank spaces between numbers, names or words) City Attorney/Representative for Injured Worker: (DATE OF BIRTH: MM/DD/YYYY) MI State Zip Code Name Address/PO Box ( Please leave blank spaces between numbers , names or words) City Lien Claimant (Completion of this section is required): State Zip Code Name of Organization filing lien (for individual lien claimants, leave blank) First Name of Individual filing lien(organizational lien claimants, leave blank) Last Name of Individual filing lien(organizational lien claimants, leave blank) Address/PO Box ( Please leave blank spaces between numbers, names or words) City Phone DWC/ WCAB Form 6 (Page 1) Rev(11/2008) State Zip Code Lien Claimant's Attorney/Representative, if any Law Firm/Attorney Non-Attorney Representative Lien Claimant not represented Lien Claimant Law Firm/Representative First Name Last Name Address/PO Box ( Please leave blank spaces between numbers, names or words) City State Zip Code Phone Employer Name Address/PO Box ( Please leave blank spaces between numbers, names or words) City Insurance Carrier or Claims Administrator State Zip Code Name Address/PO Box ( Please leave blank spaces between numbers, names or words) City Employer or Claims Administrator Attorney/Representative (if known) State Zip Code Name Address/PO Box ( Please leave blank spaces between numbers, names or words) City DWC/ WCAB Form 6 (Page 2) Rev(11/2008) State Zip Code The lien claimant hereby requests the Workers' Compensation Appeals Board to determine and allow as a lien the sum of $ Total Lien Amount against any amount now due or which may hereafter become payable as compensation to the above-named employee on account of the above-claimed injury. This request and claim for lien is for (mark appropriate box): A reasonable attorney's fee for legal services pertaining to any claim for compensation either before the appeals board or before any of the appellate courts, and the reasonable disbursements in connection therewith. (Labor Code § 4903 (a).) The reasonable expense incurred by or on behalf of the injured employee, as provided by Labor Code § 4600. (Labor Code § 4903 (b).) Reasonable expense incurred by or on behalf of the injured employee for medical-legal expenses. (Labor Code § 4903 (b).) The reasonable value of the living expenses of an injured employee or of his or her dependents, subsequent to the injury. (Labor Code § 4903 (c).) The reasonable burial expenses of the deceased employee. (Labor Code § 4903 (d).) The reasonable living expenses of the spouse or minor children of the injured employee, or both, subsequent to the date of the injury, where the employee has deserted or is neglecting his or her family. (Labor Code § 4903 (e).) The reasonable fee for interpreter's services performed on 20 . (Labor Code § 4600 (f).) The amount of indemnification granted by the California Victims of Crime Program. (Labor Code § 4903 (i).) The amount of compensation, including expenses of medical treatment, and recoverable costs that have been paid by the Asbestos Workers' Account. (Labor Code § 4903 (j).) Other Lien(s): Specify nature and statutory basis. NOTE: ITEMIZED STATEMENT JUSTIFYING THE LIEN MUST BE ATTACHED A copy of the lien claim and supporting documents was served by mail or delivered to each of the above-named parties. (Signature of Attorney/Representative for Lien Claimant) (Signature of Lien Claimant) Date (MM/DD/YYYY) DWC/ WCAB Form 6 (Page 3) Rev(11/2008)
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