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California Department of Industrial Relations Division of Workers' Compensation

Request for DWC Authorization Number
Instructions: In order to facilitate streamlined access to WCAB records, you may obtain DWC Authorization Number. You may obtain an authorization number by completing this request form and returning it to: DWC Public Records Office Division of Workers' Compensation P.O. BOX 420603 San Francisco, CA 94142 This request may also be submitted by faxing it to (510) 286-7163 Please complete the following (please print): Requestor Name: Company Name: Address: City/State/Zip: Telephone: ( )

Nature of requestor's business:

Please explain the reason(s) why you want this information.

NOTE: This Request is a Public Record and will remain on file. By making this request you are declaring that you will not use the information you receive for illegal or unlawful purposes. I, the undersigned, declare under penalty of perjury under the laws of the State of California, that I shall not use the information received pursuant to this request for illegal or unlawful purposes and that the foregoing is true and correct. Signature
(To be completed by the Division of Workers' Compensation only)

Date

******************************************************************************************************* Your request for DWC case information authorization has been granted. Your authorization number is Your request for DWC case information authorization has been denied because

DWC Form AD-3 (New 5/06)