WORKERS' COMPENSATION APPEALS BOARD ADDENDUM TO APPLICATION FOR ADJUDICATION OF CLAIM TO IDENTIFY LEGAL ENTITY EMPLOYING INJURED WORKER Case No. _____________________________________ STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION' Applicant, Defendant(s). ATTENTION DEFENDANT EMPLOYER: You have been sued by the above-named Injured Worker (Applicant) in an Application for Adjudication of Claim filed with the Workers' Compensation Appeals Board. IT IS ALLEGED THAT YOU ARE ILLEGALLY UNINSURED. The Application for Adjudication of Claim, a copy of which is attached, lists your name as: In box above, specify "Employer Name" as found at the top of page 2 of the Application for Adjudication of Claim (DWC/WCAB Form 1A) In naming you this way, Applicant intends that you be identified by the name below and, in such capacity, is suing you: In box above, specify full legal name of the Defendant BE ADVISED the legal entity named here is subject to all NOTICES contained in the SPECIAL NOTICE OF LAWSUIT served upon you together with this document. Dated at __________________________________________________, California, on _____________________________________ (CITY) (DATE) ____________________________________________________ APPLICANT'S ATTORNEY / UNREPRESENTED APPLICANT'S SIGNATURE ___________________________________________________ ADDRESS OF APPLICANT'S ATTORNEY / UNREPRESENTED APPLICANT APPLICANT'S ATTORNEY / UNREPRESENTED APPLICANT'S PRINTED NAME ____________________________________________________ ___________________________________________________ TELEPHONE NUMBER OF APPLICANT'S ATTORNEY / UNREPRESENTED APPLICANT WCAB Form 2 (8/2011) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS This Addendum is to be used where the Application for Adjudication of Claim does not set forth the full or complete legal name of the entity (defendant) allegedly employing the injured worker. Use this Addendum to more fully identify the legal entity named on the "Employer Name" line at the top of page two of the Application for Adjudication of Claim (DWC/WCAB Form 1A). A separate Addendum is to be completed for each distinct legal entity or defendant named in the Application for Adjudication of Claim. This Addendum is to be served with the Application for Adjudication of Claim and Special Notice of Lawsuit on each named defendant. A copy of this Addendum must be filed at the Workers' Compensation Appeals Board together with the Application for Adjudication of Claim, Special Notice of Lawsuit, and a Proof of Service. The Proof of Service must specifically state that the Addendum was served together with the Application for Adjudication of Claim and Special Notice of Lawsuit. PLEASE NOTE: This Addendum does not substitute for an amended application for adjudication of claim to name a different employer. WCAB Form 2 (8/2011) American LegalNet, Inc. www.FormsWorkFlow.com