Stipulation And Order To Pay Lien Claimant {WC-904}

WC-904 - STIPULATION AND ORDER TO PAY LIEN CLAIMANT. This form is used in California workers’ compensation cases to resolve and authorize payment of an approved lien. This form is filed with the Division of Workers’ Compensation when the applicant, defendant, and lien claimant agree on a reduced or full payment amount to satisfy a lien claim. It identifies the lien amount originally claimed, the agreed payment amount, the party responsible for payment, and the basis of the lien, such as medical-legal services or self-procured treatment. Once signed by the parties and approved by a workers’ compensation judge, the order requires payment to be made within 20 days. The form also includes service instructions under WCAB Rule 10500. www.FormsWorkflow.com