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Department of Industrial Relations
Division of Workers' Compensation

WORKERS' COMPENSATION APPEALS BOARD
STATE OF CALIFORNIA
) ) ) Applicant, ) ) ) ) ) ) Defendants )

Case No.

vs.

PETITION TO REOPEN

Petitioner hereby requests that the above-entitled action be reopened for the following reasons:

PROOF OF SERVICE (WCAB RULE 10514) On _____________ at ___________________
(date) (place)

____________________________________ Petitioner

Copy mailed to following addresses: _____________________________________ ____________________________________ Address ____________________________________ Attorney for Petitioner ____________________________________ Address of Attorney

_____________________________________

_____________________________________

___________________________
(Signature )

DWC/WCAB FORM 42 (REV. 8-85)