Application For Subsequent Injuries Fund Benefits

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STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
WORKERS' COMPENSATION APPEALS BOARD
APPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITS
Case Number 1
Case Number 4
Case Number 2
Case Number 5
Case Number 3
Injured Worker
MI
First Name
Last Name
VS
Employer Name
Insurance Carrier Name
Third Party Administrator
APPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITS
1. Applicant
, born on
MM/DD/YYYY
was injured on
, as a
at
MM/DD/YYYY
California, with earnings of $
per
Applicant sustained injury arising out of and occurring in the course of his/her employment resulting in permanent and
partial disability affecting the following parts of the body:
The permanent disability, when considered alone and without regard to or adjustment for the applicant’s occupation or
age is equal to
percent or more of total disability.
Application for SIF Benefits - Version 11/2008
APPSIF

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