Declaration Statement Of Compliance With Labor Code Sections 139.3 And 4906(g) | Pdf Fpdf Doc Docx | California

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Declaration Statement Of Compliance With Labor Code Sections 139.3 And 4906(g) | Pdf Fpdf Doc Docx | California

Declaration Statement Of Compliance With Labor Code Sections 139.3 And 4906(g)

This is a California form that can be used for General within Workers Comp.

Alternate TextLast updated: 5/30/2015

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DECLARATION STATEMENT OF COMPLIANCE WITH LABOR CODE SECTIONS 139.3 AND 4906(g) I, (PRINT YOUR NAME) hereby state, and declare under penalty of perjury, that I have not violated the provisions of Labor Code section 139.3 and I have not offered, delivered, received, or accepted any rebate, refund, commission, preference, patronage, dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for any referred examination or evaluation. Signed (DECLARANT'S SIGNATURE) , California, on Declared at (PLACE SIGNED-PRINT CITY) (DATE DECLARATION SIGNED) I am the Applicant/ Employee Insurer Representative Self-Insured Representative Employer/ Defendant Attorney for Applicant Attorney for Defendant Other DIR WCAB-LBOI&A UNIT/NON-STD FORM American LegalNet, Inc. www.FormsWorkFlow.com

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