WORKERS' COMPENSATION APPEALS BOARD

STATE OF CALIFORNIA SEE REVERSE SIDEDEPARTMENT OF INDUSTRIAL RELATIONS FOR INSTRUCTIONS WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR ADJUDICATION OF CLAIM (Death Case) (PRINT OR TYPE NAMES AND ADDRESSES) (APPLICANT) (DECEASED EMPLOYEE) Social Security No. (EMPLOYER - STATE IF SELF-INSURED) (EMPLOYER'S INSURANCE CARRIER OR, IF SELF-INSURED, ADJUSTING AGENCY) IT IS CLAIMED THAT: CASE No. (APPLICANT'S ADDRESS AND ZIP CODE) (EMPLOYER'S ADDRESS AND ZIP CODE) (INSURANCE CARRIER OR ADJUSTING AGENCY'S ADDRESS) employee, bornwhile as employed as a (DATE OF BIRTH) (OCCUPATION AT TIME OF INJURY) on , at , by the employer sustained (DATE OF INJURY) (ADDRESS) (CITY) (STATE) (ZIP CODE) injury arising out of and in the course of employment to (STATE WHAT PARTS OF BODY WERE INJURED) injury occurred as follows:(EXPLAIN WHAT EMPLOYEE WAS DOING AT TIME OF INJURY AND HOW INJURY WAS RECEIVED) resulting in death on (DATE OF DEATH) earnings at time of injury were:(GIVE WEEKLY OR MONTHLY SALARY OR HOURLY RATE AND NUMBER OF HOURS)

of the Workers’ Compensation Appeals Board’s Rules of Practice and Procedure. If you have no attorney or agent, copies of this application will be served by the Division of Workers’ Compensation on all parties. If you file any other document, you must mail or deliver a copy of the document to all parties in the case.

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