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Request For WCAB Case Number Search Form. This is a California form and can be use in General Workers Comp.
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Tags: Request For WCAB Case Number Search, DWC-AD2, California Workers Comp, General
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. California Department of Industrial Relations : Calendar No. Division of Workers' Compensation : Request for Plaintiff(s) Case # JUDICIAL SUBPOENA WCAB Search INSTRUCTIONS: In order to look at a WCAB case file, you must make the request in person at the DWC district office and provide both the name of the injured worker and the WCAB Case Number. -against- : : If you have an Authorization number, you may go directly to WCAB district office in order to be given the WCAB case number and access to the WCAB case files by district office: personnel. Defendant(s) : . and .mailing. it . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to: If you do not have an Authorization number, you may obtain the WCAB case number by completing this form DWC Public Records Office Division of Workers' Compensation P O BOX 420603 THE PEOPLE OF THE STATE OF NEWFrancisco, CA 94102 San YORK (415) 703-4600 TO 1. Please complete the following (please print): Requestor Name: GREETINGS: DWC Authorization # (if any): WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Company Name: , the Honorable at the Court located at County of Address: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the City/State/Zip: Telephone: Your failure business: Nature of requestor's to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. If you are making this request on behalf of another, please provide the following data about Court in County, day of , 20 the person or entity you represent: 2. Name: (Attorney must sign above and type name below) Witness, Honorable , one of the Justices of the Company Name: Address: City/State/Zip: Telephone: Nature of requestor's business: Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: DWC Form AD-2 (New 1/96) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index California Department of Industrial Relations No. : Calendar No. Request for WCAB Case # Search Page 2 Division of Workers' Compensation Plaintiff(s) 3. : JUDICIAL SUBPOENA Please explain why -againstyou want this information and/or the reasons why your client wants : this information. : : Defendant(s) : ...................................................... 4. Please provide as much identifying information as possible about this case: Injured Worker's Name: THE PEOPLE OF THE STATE OF NEW YORK TO Social Security No. of Injured Worker: Date of Birth: Employer: Date of Injury: GREETINGS: Insurance Carrier: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court located at County of in room below and return thisday of as indicated 20 the ,instructions. , on the , in at o'clock in the noon, and at any recessed Sign form 5. or adjourned date, to testify and give evidence as a witness in this action on the part of the the Part Injured: Body Honorable NOTE: This Request is a Public Record. A record of this request will be retained by the DWC Public Records Office. By making this request you are declaring that you will not use the information you receive for illegal or unlawful purposes. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whosedeclare this subpoena was perjuryfor a maximum penalty State of California, thatsustained as a behalf under penalty of issued under the laws of the of $50 and all damages I shall I, the undersigned, result of your failure to comply. pursuant to this request for illegal or unlawful purposes and that the not use the information received foregoing is true and correct. Witness, Honorable Court in County, , one of the Justices of the day of , 20 Signature Date ********************************************************************************************************************************* (Attorney must sign above and type name below) (To be completed by the Division of Workers' Compensation only) Your request for WCAB case identification has been granted. WCAB case no.: Attorney(s) for File Location: We were unable to locate a WCAB case number for the injured worker. Office and P.O. Address Your request for WCAB case identification has been denied because: Form not properly completed (see area circled). Form not signed. Other: Telephone No.: Facsimile No.: Form illegible. E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com