DISCLAIMER The following statement by the undersigned is made in accordance with California Workers' Compensation Labor Code 4906 (g): "Under penalty of perjury, I affirm that I have not violated section 139.3, and that I have not offered, delivered, received, or accepted any rebate, refund, commission, preference, patronage, dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for any referred examination or evaluation." Applicant Date Employer Date Defendant Date Defendant's Attorney Date WC-4 2002 © American LegalNet, Inc.