Free IWGuide05.pm - California


File Size: 377.2 kB
Pages: 1
File Format: PDF
State: California
Category: Workers Compensation
Author: Richard Stephens
Word Count: 143 Words, 1,262 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dir.ca.gov/dwc/FORMS/DWC_Form49.pdf

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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 Commutation of Future Payments
NOTICE: Order may issue granting petition for commutation unless objection is filed within (10) days after date of service

1. Applicant requests

(A) that all future payments be commuted to a lump sum. (B) that sufficient final weekly payments be commuted to produce the sum of $________ (Strike out part not applicable)

2. The reason for requesting commutation is:

NOTE: Good cause must be shown under Labor Code Section 5100. No attorney fee will be allowed unless Requested. Dated:____________________________ Copies mailed to the following on Petitioner_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 19_ _ _

Attorney for Petitioner

___________________________________

ORDER COMMUTATION IS HEREBY ORDERED AS FOLLOWS:

Dated: ________________________________
Served by mail on persons shown on the official address record

_________________________________________
WORKERS' COMPENSATION JUDGE

By: __________________________________
DWC/WCAB FORM 49 (REV. 11-74)