STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD ID OR CASE NO. PETITION FOR PRE- APPLICATION DISCOVERY ORDER (PRINT OR TYPE NAMES AND ADDRESSES; INCLUDE ZIP CODES) Injured Worker Date of Claimed Injury Attorney for Injured Worker Employer Insurance Carrier or, if Self-Insured, Certificate Name Address Social Security Number Address Address Date of Birth Address Where Claim Administered Adjusting Agency, if Agency Administered Attorney for Employer/Carrier Address 1. carrier other , , injured worker employer in connection with the claimed injury listed above, petitions for the following: Order Compelling Appearance at Medical Examination. Order Compelling Appearance at Deposition. Order Compelling Release of Documents. Order Prohibiting Medical Examination. Order Quashing Subpoena/Subpoena Duces Tecum. (Attach copy of subpoena) Quashing Deposition. (Attach copy of deposition notice) Order Suspending Proceedings (Labor Code section 4053) Order Barring Compensation (Labor Code section 4054) Other: 2. Petitioner requests the following specific action: WCAB Form 30 (Rev. 2/91) (Page 1 of 2) WCAB-30 2002 © American LegalNet, Inc. DECLARATION IN SUPPORT OF PETITION STATE OF CALIFORNIA, COUNTY OF The undersigned states: the petitioner (one of) the attorney(s) of record/representative(s) for the petitioner. That the following facts justify the action requested: That he/she is: I declare under penalty of perjury that the foregoing is true and correct, except for the allegations made on information and belief. Executed on , , at , California. Signature Address Telephone PROOF OF SERVICE Proof of service may be made as follows: " (a) affidavit or declaration of service; " (b) written statement endorsed upon the document served and signed by the party or lien claimant making the statement; " (c) letter of transmittal. " The Proof of Service shall set forth the names and addresses of persons served, whether such service was made personally or by mail, the date of service, the place of personal service or the address to which mailing was made. " California Code of Regulations, title 8, section 10975 (WCAB Rules of Practice and Procedure) WCAB Form 30 (Rev. 2/91) (Page 2 of 2) 2002 © American LegalNet, Inc.