Dwc Wcab Form 6 PDF Details

DWC Wcab form 6 is an important document when it comes to workers' compensation. This document is used to report any workplace injuries that have occurred, and it's important to understand the process so you can get the help you need as quickly as possible. In this post, we'll go over what DWC Wcab form 6 is and how to complete it correctly. We'll also highlight some of the benefits of reporting your injury in a timely manner.

If you want to first determine how much time you will need to fill out the dwc wcab form 6 and the number of pages it has, here's some detailed data that could be of use.

QuestionAnswer
Form NameDwc Wcab Form 6
Form Length3 pages
Fillable?Yes
Fillable fields58
Avg. time to fill out12 min 25 sec
Other nameswcab form, 2008, Claimant, wcab forms

Form Preview Example

STATE OF CALIFORNIA

DIVISION OF WORKERS' COMPENSATION

WORKERS' COMPENSATION APPEALS BOARD NOTICE AND REQUEST FOR ALLOWANCE OF LIEN

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)

 

 

City

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Handful of tasks are quicker than completing documentation with the help of this PDF editor. There isn't much you should do to edit the DWC form - only adopt these measures in the following order:

Step 1: Click on the "Get Form Here" button.

Step 2: At this point, you can start modifying your DWC. Our multifunctional toolbar is readily available - insert, remove, change, highlight, and undertake other commands with the content material in the file.

The next segments will make up the PDF document that you will be creating:

portion of fields in therewith

You have to fill out the S, SN (Numbers Only) Injured Worker:, First Name, Last Name, Address, PO Box ( Please leave, City Attorney, Representative for, State, Zip Code, Name, and Address, PO Box ( Please leave space with the essential particulars.

therewith SSN (Numbers Only) Injured Worker:, First Name, Last Name, Address/PO Box ( Please leave, City Attorney/Representative for, State, Zip Code, Name, and Address/PO Box ( Please leave blanks to insert

The program will ask you for information to instantly submit the part Address, PO Box ( Please leave, City, State, Zip Code, Lien Claimant (Completion of this, Name of Organization filing lien, First Name of Individual filing, Last Name of Individual filing, Address, PO Box ( Please leave, City, State, and Zip Code.

part 3 to finishing therewith

The space Law Firm, Attorney Non, Attorney Representative, Lien Claimant not represented, Lien Claimant Law, First Name, Last Name, Address, PO Box ( Please leave, City, State, and Zip Code is going to be where one can indicate each side's rights and responsibilities.

therewith Law Firm/Attorney, Non-Attorney Representative, Lien Claimant not represented, Lien Claimant Law, First Name, Last Name, Address/PO Box ( Please leave, City, State, and Zip Code blanks to fill

Finalize by reading the following fields and filling them in accordingly: Phone Employer, Name, Address, PO Box ( Please leave, City, Insurance Carrier or Claims, Name, State, Zip Code, and Address, PO Box ( Please leave.

Entering details in therewith stage 5

Step 3: As soon as you are done, press the "Done" button to transfer your PDF form.

Step 4: Get a minimum of a few copies of the document to keep clear of any future challenges.

Watch Dwc Wcab Form 6 Video Instruction

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