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STATE OF CALIFORNIA
Department of Industrial Relations
Division of Workers' Compensation

WORKERS' COMPENSATION APPEALS BOARD
) ) ) Applicant, ) ) ) ) ) ) Defendants )

Case No.

vs.

Petition for Reconsideration

A decision was filed in the above-entitled case on ___________________________________________. The ___________________________________________________________ is aggrieved by said decision and hereby petitions for reconsideration upon the following grounds: (strike out items not applicable) 1. By the order, decision or award, the Board acted without or in excess of its powers. 2. The order, decision, or award was procured by fraud. 3. The evidence does not justify the findings of fact. 4. Petitioner has discovered new evidence material to him which he could not with reasonable diligence have discovered and produced at the hearing. 5. The findings of fact do not support the order, decision or award. In support of the above, petitioner gives the following details, including a statement of facts upon which petitioner relies and a discussion of the law applicable thereto:

DWC/WCAB Form 45 (Page 1) (Rev 3-76)

WHEREFORE, Petitioner requests that reconsideration be granted; that further proceedings be had; and that decision be made to give petitioner all the benefits to which he is entitled under the Labor Code of the State of California, including the relief requested herein.

_______________________________ Attorney for Petitioner STATE OF CALIFORNIA County of ________________ ) ) )

_______________________________ Petitioner

vs.

I, the undersigned, say that I am _____________________________________________ ________________________________________________________________________ in the above-entitled action. I have read the foregoing petition for reconsideration and know the contents thereof, and that the same is true of my own knowledge, except as to the matters which are therein stated upon my information or belief, and as to those matters that I believe it to be true. I declare under penalty of perjury that the foregoing is true and correct.

Executed on ______________________, 19 ____ at __________________________ California. _______________________________ Petitioner NOTE: If verification is by attorney or officer of a corporation it must comply with Section 446 Code of Civil Procedure.) Copy mailed to: Date of Mailing:

By: ______________________________________ (Signature)

DWC/WCAB FORM 45 (Page 2) (REV. 3-76)

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