Application For Subsequent Injuries Fund Benefits Page 2
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22. Immediately prior to the injury, applicant was permanently disabled in the following respects
The pre-existing disabilities occurred as a result of:
3. Applicant has previously filed a workers’ compensation claim with the Workers’ Compensation Appeals Board
Case Number
4. Applicant filed for Social Security Disability benefits on
and is receiving $
per month. Applicant’s Social Security Number is
WHEREFORE, applicant requests benefits as provided by law
Attorney for Applicant Signature
Applicant Signature
Street Address/PO Box (Please leave blank spaces between numbers, names or words)
State
City
Zip Code
APPSIF
Application for SIF Benefits - Version 11/2008
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