Complaint About A Workers' Compensation Administrative Law Judge
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DEPARTMENT OF INDUSTRIAL RELATIONS
WORKERS’ COMPENSATION ETHICS ADVISORY COMMITTEE
Complaint About a Workers’ Compensation Administrative Law Judge
(Labor Code §123.6 and Title 8, Cal. Code Regs. §9722.1)
Date:__________________________
Your
Your name:__________________________________________ telephone number:___________________
Your address:___________________________________________________________________________
Your attorney’s
Your attorney’s name (if any):___________________________ phone number:______________________
Judge’s name:________________________________________ WCAB Case No.:____________________
Name of the WCAB case:_________________________________________________________________
In the space below, please specify exactly what action or behavior
of the judge you believe is an ethical violation.
Please provide relevant dates and the names of others present.
Use additional sheets if needed.
____________________________________________________________________________________________________________
It may be a felony to make or cause to be made any knowingly false or fraudulent material statements in support of,
or in opposition to, any claim for workers’ compensation benefits. Your signature below indicates that you have
read and understood the above statement.
Date: _____________________
Signature: ___________________________________________________
Return to:
Department of Industrial Relations
Workers’ Compensation Ethics Advisory Committee
P.O. Box 420603
San Francisco, CA 94142-0603
Note: Filing a complaint with the Ethics Advisory Committee is NOT a Petition for Reconsideration or Appeal of an
Award or Order. Filing a complaint will NOT result in a reversal or change in any decision already made by the
judge.
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