WORKERS' COMPENSATION APPEALS BOARD LIEN CLAIM RETURN FORM The attached Notice and Request for Lien is being returned to you because: You did not use the current form. A blank copy of the current form is attached. There is insufficient identifying information on the lien form. Please provide the information in the blanks marked in the form. The lien is for an injury occurring on or after January 1, 1990, and no Application for Adjudication of Claim has been filed. Therefore, the lien must be accompanied by (1) a copy of the original completed Employee's Claim for Workers' Compensation Benefits (DWC Form 1) or (2) a declaration under penalty of perjury specifying the efforts you made to secure a copy of the original completed DWC Form 1. (See WCAB Rule 10770, as amended effective January 1, 1991.) Other WC-2 2002 © American LegalNet, Inc.