STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD NOTICE AND REQUEST FOR ALLOWANCE OF LIEN Injured Worker: Attorney/Representative for Injured Worker: DWC/ WCAB Form 6 (Page 1) Rev(11/2008) Lien Claimant (Completion of this section is required):(Choose only one)(DATE OF INJURY: MM/DD/YYYY)(START DATE: MM/DD/YYYY)(END DATE: MM/DD/YYYY)MM/DD/YYYY Case No. Original Lien Amended Lien and ended on which began on on (DATE OF BIRTH: MM/DD/YYYY) MI Zip Code City Address/PO Box ( Please leave blank spaces between numbers, names or words) Last Name First Name Zip Code City Address/PO Box ( Please leave blank spaces between numbers , names or words) Name Name of Organization filing lien (for individual lien claimants, leave blank) First Name of Individual filing lien(organizational lien claimants, leave blank) Last Name of Individual filing lien(organizational lien claimants, leave blank) Address/PO Box ( Please leave blank spaces between numbers, names or words) City Zip Code Phone SSN (Numbers Only) a specific injury a cumulative injury Date Of Original Lien: State State State Employer or Claims Administrator Attorney/Representative (if known) Insurance Carrier or Claims Administrator Employer Lien Claimant's Attorney/Representative, if any DWC/ WCAB Form 6 (Page 2) Rev(11/2008) Lien Claimant Law Firm/Representative First Name Last Name Address/PO Box ( Please leave blank spaces between numbers, names or words) City Zip Code Phone Zip Code City Address/PO Box ( Please leave blank spaces between numbers, names or words) Name Zip Code City Address/PO Box ( Please leave blank spaces between numbers, names or words) Name Name Address/PO Box ( Please leave blank spaces between numbers, names or words) City Zip Code Law Firm/Attorney Non-Attorney Representative Lien Claimant not represented State State State State This request and claim for lien is for (mark appropriate box): The lien claimant hereby requests the Workers' Compensation Appeals Board to determine and allow as a lien the sum of $ against any amount now due or which may hereafter become payable ascompensation to the above-named employee on account of the above-claimed injury. NOTE: ITEMIZED STATEMENT JUSTIFYING THE LIEN MUST BE ATTACHED (Signature of Attorney/Representative for Lien Claimant) (Signature of Lien Claimant)Date (MM/DD/YYYY) DWC/ WCAB Form 6 (Page 3) Rev(11/2008) Total Lien Amount A reasonable attorney's fee for legal services pertaining to any claim for compensation either before the appeals board or before any of the appellate courts, and the reasonable disbursements in connection therewith. (Labor Code § 4903 (a).) The reasonable expense incurred by or on behalf of the injured employee, as provided by Labor Code § 4600. (Labor Code § 4903 (b).) Reasonable expense incurred by or on behalf of the injured employee for medical-legal expenses. (Labor Code § 4903 (b).) The reasonable value of the living expenses of an injured employee or of his or her dependents, subsequent to the injury. (Labor Code § 4903 (c).) The reasonable burial expenses of the deceased employee. (Labor Code § 4903 (d).) The reasonable living expenses of the spouse or minor children of the injured employee, or both, subsequent to the date of the injury, where the employee has deserted or is neglecting his or her family. (Labor Code § 4903 (e).) The reasonable fee for interpreter's services performed on The amount of indemnification granted by the California Victims of Crime Program. (Labor Code § 4903 (i).) The amount of compensation, including expenses of medical treatment, and recoverable costs that have been paid by the Asbestos Workers' Account. (Labor Code § 4903 (j).) Other Lien(s): Specify nature and statutory basis. 20 . (Labor Code § 4600 (f).) A copy of the lien claim and supporting documents was served by mail or delivered to each of the above-named parties.