Dwc Wcab Form 6 PDF Details

In the bustling world of workers' compensation in California, the DWC WCAB Form 6 serves as a critical document for lien claimants seeking to assert their right to payment from an injured worker's compensation case. This form, intricately designed by the State of California’s Division of Workers' Compensation and the Workers' Compensation Appeals Board, is utilized to notify the necessary parties and formally request the allowance of a lien. It encompasses a variety of claims, including but not limited to attorney's fees, medical and medical-legal expenses, living expenses of the injured worker or their dependents, burial expenses, and even compensation granted by the California Victims of Crime Program. The form must be meticulously completed, detailing the original lien or amending a previous one, and it specifies the nature of the injury sustained by the worker—be it specific or cumulative. Furthermore, it mandates the inclusion of an itemized statement justifying the lien and requires that a copy of the claim and supporting documents be served to all involved parties. The precise completion and submission of this form play a pivotal role in the workers' compensation appeals process, impacting both the injured worker and the lien claimant in significant ways.

QuestionAnswer
Form NameDwc Wcab Form 6
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameswcab form, WCAB, wcab fillable forms, disbursements

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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION

WORKERS' COMPENSATION APPEALS BOARD

NOTICE AND REQUEST FOR ALLOWANCE OF LIEN

Print Form

Date Of Original Lien:

MM/DD/YYYY

Case No.

(Choose only one)

a specific injury on

(DATE OF INJURY: MM/DD/YYYY)

Original Lien

Amended Lien

a cumulative injury which began on

and ended on

 

(START DATE: MM/DD/YYYY)

 

(END DATE: MM/DD/YYYY)

SSN (Numbers Only)

Injured Worker:

(DATE OF BIRTH: MM/DD/YYYY)

 

First Name

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address/PO Box ( Please leave blank spaces between numbers, names or words)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

 

Zip Code

 

 

Attorney/Representative for Injured Worker:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address/PO Box ( Please leave blank spaces between numbers , names or words)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lien Claimant (Completion of this section is required):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DWC/ WCAB Form 6 (Page 1) Rev(11/2008)

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code

 

 

 

City

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Carrier or Claims Administrator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address/PO Box ( Please leave blank spaces between numbers, names or words)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

Zip Code

 

 

Employer or Claims Administrator Attorney/Representative (if known)

Name

Address/PO Box ( Please leave blank spaces between numbers, names or words)

 

 

 

 

Zip Code

City

State

DWC/ WCAB Form 6 (Page 2) Rev(11/2008)

The lien claimant hereby requests the Workers' Compensation Appeals Board to determine and allow as a lien the sum

of $

against any amount now due or which may hereafter become payable as

Total Lien Amount

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)

How to Edit Dwc Wcab Form 6 Online for Free

We've applied the hard work of our best programmers to make the PDF editor you are about to make use of. The application will allow you to prepare the wcab forms file easily and don’t waste valuable time. Everything you should undertake is adhere to these straightforward steps.

Step 1: Choose the "Get Form Here" button.

Step 2: At this point, you can begin editing your wcab forms. The multifunctional toolbar is readily available - insert, erase, transform, highlight, and carry out various other commands with the words and phrases in the document.

Provide the content demanded by the application to fill out the file.

CALIFORNIA blanks to fill in

Type in the details in the City AttorneyRepresentative for, Name, AddressPO Box Please leave blank, City, State, Zip Code, Lien Claimant Completion of this, Name of Organization filing lien, First Name of Individual filing, and Last Name of Individual filing area.

Filling in CALIFORNIA step 2

It is important to insert specific information in the area AddressPO Box Please leave blank, City, State, Zip Code, and Phone DWC WCAB Form Page Rev.

Finishing CALIFORNIA stage 3

The Lien Claimants, Law FirmAttorney, NonAttorney Representative, Lien Claimant not represented, Lien Claimant Law, First Name, Last Name, AddressPO Box Please leave blank, City, Phone Employer, State, and Zip Code segment has to be applied to provide the rights or responsibilities of each party.

Filling in CALIFORNIA stage 4

Finalize by analyzing the next sections and completing the proper particulars: Phone Employer, Name, AddressPO Box Please leave blank, City, Insurance Carrier or Claims, Name, State, Zip Code, AddressPO Box Please leave blank, City, State, Zip Code, and Employer or Claims Administrator.

Finishing CALIFORNIA step 5

Step 3: When you have selected the Done button, your form will be accessible for export to any type of electronic device or email you indicate.

Step 4: You can also make copies of your document tostay away from all of the future concerns. You should not worry, we do not disclose or check your details.

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