Represented Additional Panel Proof Of Service

PROOF OF SERVICE BY MAIL.This form is used to certify that an Additional Panel Order in a represented workers’ compensation case has been properly served on all required parties. The declarant must confirm their residency or employment in the county where mailing occurred, state their address, identify the date of mailing, and affirm that a true copy of the Additional Panel Order was enclosed in a sealed, postage-paid envelope and deposited in the U.S. mail. The declaration is executed under penalty of perjury and includes signature, printed name, city, and date of execution. This proof ensures compliance with mailing and notification requirements for Additional QME Panel orders issued by the Division of Workers’ Compensation. www.FormsWorkflow.com