STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD Case No. Applicant VS. Petition for Appointment of Guardian ad Litem and Trustee Defendants As a result of an alleged industrial injury on to Injured Employee , while employed by benefits are claimed by Employer the following minor(s)/incompetent(s): Strike inapplicable matter Name Date of Birth The minor(s)/incompetent(s) require a Guardian ad Litem and Trustee to prosecute the claim and to receive Strike inapplicable matter and receipt for any benefits awarded or voluntarily furnished. The Workers' Compensation Appeals Board is requested to appoint , as Guardian ad Litem and Trustee. * who has legal custody of, and is legally responsible for the support of the minor(s). ( * Strike if not applicable.) We hereby join in the above request. , Relationship if any Date , Petitioner Address NOTE: Consent must be signed by all minors over 14 years of age and by all adults with sufficient capacity to form an intelligent preference. Attorney for Petitioner Address and telephone number DIA WCAB FORM 8 (REV. 10-90) WCAB-8 2002 © American LegalNet, Inc.