STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
WORKERS' COMPENSATION APPEALS BOARD
NOTICE AND REQUEST FOR ALLOWANCE OF LIEN
Date Of Original Lien:
Original Lien Amended Lien
MM/DD/YYYY
Case No.
(Choose only one)
a specific injury
on
(DATE OF INJURY: MM/DD/YYYY)
a cumulative injury
which began on and ended on
(START DATE: MM/DD/YYYY)
(END DATE: MM/DD/YYYY)
(DATE OF BIRTH: MM/DD/YYYY)
SSN (Numbers Only)
Injured Worker:
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)
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Lien Claimant's Attorney/Representative, if any
Non-Attorney Representative
Lien Claimant not represented
Law Firm/Attorney
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
Insurance Carrier or Claims Administrator
Name
Address/PO Box ( Please leave blank spaces between numbers, names or words)
City
Employer or Claims Administrator Attorney/Representative (if known)
Name
State
State
Zip Code
Zip Code
Address/PO Box ( Please leave blank spaces between numbers, names or words)
DWC/ WCAB Form 6 (Page 2) Rev(11/2008)
City
State
Zip Code
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).)
20 . (Labor Code § 4600 (f).)
The reasonable fee for interpreter's services performed on
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)
