Free Application for discretionary payments from the Uninsured Employers' Fund - California

Reset Form

Print Form

APPLICATION FOR DISCRETIONARY PAYMENTS FROM THE UNINSURED EMPLOYERS' FUND

Case Number

SSN (Numbers Only) Applicant (Completion of this section is required) First Name MI

Last Name

Street Address1/PO Box (Please leave blank spaces between numbers, names or words)

Street Address2/PO Box (Please leave blank spaces between numbers, names or words)

City Uninsured Employers Benefit Trust Fund

State

Zip Code

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

CA
City State Zip Code Prompt consideration of your application requires COMPLETE and FULL ANSWERS TO ALL THE QUESTIONS appearing below 1. Employer

Name

Street Address1/PO Box (Please leave blank spaces between numbers, names or words)

Street Address2/PO Box (Please leave blank spaces between numbers, names or words)

City
DWC / UEF 50 Rev: 11/2008 - Page 1

State

Zip Code

UEF50

2. Please specify a specific injury date or specify if it was a cumulative trauma injury: (Choose only one)
as specific Injury on
(DATE OF INJURY: MM/DD/YYYY)

a cumulative trauma which began on

(Start Date: MM/DD/YYYY)

and ended on

(End Date: MM/DD/YYYY)

3. List the names and address of doctors and hospitals that have treated you for this injury:

4. Have you returned to work ? If Yes, give date
(MM/DD/YYYY)

Yes

No

5. Have you received payments from anyone for this injury ? If Yes, how much were you paid ? $ Who paid you ?

Yes

No

I, the undersigned, hereby apply for discretionary payments of compensation from the Uninsured Employers Fund under Laber Code section 4903.3 and declare under penalty of perjury that the information furnished above is true and correct to the best of my knowledge and belief. I hereby authorize any doctors or hospitals that have treated me for this injury to furnish and disclose all facts concerning my medical condition that are within their knowledge, and to allow inspection of and provide copies of any records concerning my medical condition that are under their control.

Executed on

(MM/DD/YYYY)

,at

, California

( Signature of Applicant )

DWC / UEF 50 Rev: 11/2008 - Page 2

UEF50