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STATE OF CALIFORNIA
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DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS' COMPENSATION
WORKERS' COMPENSATION APPEALS BOARD
Case No.
Applicant
VS.
Petition for Appointment of Guardian ad Litem and Trustee
Defendants
As a result of an alleged industrial injury on to
Injured Employee
, while employed by benefits are claimed by
Employer
the following minor(s)/incompetent(s):
Strike inapplicable matter
Name
Date of Birth
The minor(s)/incompetent(s) require a Guardian ad Litem and Trustee to prosecute the claim and to receive
Strike inapplicable matter
and receipt for any benefits awarded or voluntarily furnished. The Workers' Compensation Appeals Board is requested to appoint , as Guardian ad Litem and Trustee. * who has legal custody of, and is legally responsible for the support of the minor(s).
( * Strike if not applicable.) We hereby join in the above request. Relationship if any
,
Date
,
Petitioner Address
NOTE: Consent must be signed by all minors over 14 years of age and by all adults with sufficient capacity to form an intelligent preference.
Attorney for Petitioner
Address and telephone number
DIA WCAB FORM 8 (REV. 10-90) WCAB-8