STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD LIEN CONFERENCE DISPOSITION FORM Case Name: _______________________________ ADJ No.: ______________________________ Instructions: Use this to inform the WCAB which liens have been resolved and how. Check the appropriate box or boxes and fill in the information. Use UANs for the lien representatives. Print Neatly. The following lien claims are settled: _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount _____________________________________________________________________________________________ Lien Claimant Lien Representative Lien Order or by Agreement Amount "Notice of Intent to Dismiss Lien Claim" issued as follows: _____________________________________________________________________________________________ Lien Claimant Lien Representative Date of Notice _____________________________________________________________________________________________ Lien Claimant Lien Representative Date of Notice The following lien claimants are not pursuing their lien claims and withdraw their liens: _____________________________________________________________________________________________ Lien Claimant Lien Representative Date of withdrawal _____________________________________________________________________________________________ Lien Claimant Lien Representative Date of withdrawal _____________________________________________________________________________________________ Lien Claimant Lien Representative Date of withdrawal Signatures: This information is true and accurate. _____________________________________________________________________________________________ Print name of person submitting this form Signature Date WCAB Form 27 (Revised 2013) American LegalNet, Inc. www.FormsWorkFlow.com