Free Application for SIF Benefits - California

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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITS
Case Number 1 Case Number 4

Case Number 2

Case Number 5

Case Number 3 Injured Worker

First Name

MI

Last Name

VS

Employer Name

Insurance Carrier Name

Third Party Administrator

APPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITS 1. Applicant was injured on
MM/DD/YYYY

, born on
MM/DD/YYYY

, as a California, with earnings of $ per

at

Applicant sustained injury arising out of and occurring in the course of his/her employment resulting in permanent and partial disability affecting the following parts of the body:

The permanent disability, when considered alone and without regard to or adjustment for the applicant's occupation or age is equal to
Application for SIF Benefits - Version 11/2008

percent or more of total disability. APPSIF

2. Immediately prior to the injury, applicant was permanently disabled in the following respects

The pre-existing disabilities occurred as a result of:

3. Applicant has previously filed a workers' compensation claim with the Workers' Compensation Appeals Board Case Number 4. Applicant filed for Social Security Disability benefits on and is receiving $ per month. Applicant's Social Security Number is

WHEREFORE, applicant requests benefits as provided by law
Attorney for Applicant Signature Applicant Signature

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

City

State

Zip Code

Application for SIF Benefits - Version 11/2008

APPSIF