Dwc-Ca Form 10214 - State Of California Division Of Workers' Compensation Workers' Compensation Appeals Board Third Party Compromise And Release - 2008 Page 2

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Applicant's Attorney or Authorized Representative:
Non Attorney Representative
Law Firm/Attorney
First Name
Last Name
Firm Number
Law Firm Name
Street Address/PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
Defendant's Attorney or Authorized Representative:
Law Firm/Attorney
Non Attorney Representative
First Name
Last Name
Firm Number
Law Firm Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City
Zip Code
State
Insurance Carrier Information (If applicable - include even if carrier is adjusted by claims administrator)
Insurance Carrier Name (Please leave blank spaces between numbers, names or words)
Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
DWC-CA form 10214 (e) (PAGE 2) (REV. 11/2008)

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