Dwc District Office California Form Pack Page 16
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SAMPLE
Department of Industrial Relations
Division of Workers' Compensation
WORKERS' COMPENSATION APPEALS BOARD
STATE OF CALIFORNIA
)
EAMS/WCAB
your WCAB case number
Case No.
)
YOUR NAME
Your Name
)
)
Applicant,
vs.
)
PETITION TO REOPEN
)
)
YOUR EMPLOYER AND
)
Your employer and insurance company
INSURANCE COMPANY
)
Defendants
)
Petitioner hereby requests that the above-entitled action be reopened for the following reasons:
EXPLAIN IN YOUR WORDS WHY YOU FEEL YOUR CASE SHOULD BE REOPENED
Explain in your words why you feel your case should be reopened
DWC/WCAB FORM 42 (REV. 8-85)
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