STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD SPECIAL NOTICE OF LAWSUIT (Pursuant to Labor Code 3716 and Code of Civil Procedure Sections 412.20 and 412.30) WCAB NO.: To: DEFENDANT, ILLEGALLY UNINSURED EMPLOYER: AVISO: Usted está siendo demandado. La corte puede expedir una decisión en contra suya sin darle la oportunidad de defenderse a menos que usted actue pronto. Lea la siguiente información. Applicant. Defendant(s). NOTICES 1) A lawsuit, the Application for Adjudication of Claim, has been filed with the Workers' Compensation Appeals Board against you as the named defendant by the above-named applicant(s). You may seek the advice of an attorney in any matter connected with this lawsuit and such attorney should be consulted promptly so that your response may be filed and entered in a timely fashion. If you do not know an attorney, you may call an attorney reference service or a legal aid office. You may also request assistance / information from an Information and Assistance Officer of the Division of Workers' Compensation. (See telephone directory.) 2) An Answer to the Application must be filed and served within six days of the service of the Application pursuant to Appeals Board rules; therefore, your written response must be filed with the Appeals Board promptly; a letter or phone call will not protect your interests. 3) You will be served with a Notice(s) of Hearing and must appear at all hearings or conferences. After such hearing, even absent your appearance, a decision may be made and an award of compensation benefits may issue against you. The award could result in the garnishment of your wages, taking of your money or property, or other relief. If the Appeals Board makes an award against you, your house or other dwelling or other property may be taken to satisfy that award in a non-judicial sale, with no exemptions from execution. A lien may also be imposed upon your property without further hearing and before the issuance of an award. 4) You must notify the Appeals Board of the proper address for the service of official notices and papers and notify the Appeals Board of any changes in that address. TAKE ACTION NOW TO PROTECT YOUR INTERESTS! Issued by: WORKERS' COMPENSATION APPEALS BOARD Name and Address of Appeals Board: Name and Address of Applicant's Attorney: FORM COMPLETED BY: Telephone No.: NOTICE TO THE PERSON SERVED: You are served: 1. [ ] as an individual defendant 2. [ ] as the person sued under the fictitious name of (specify): 3. [ ] on behalf of (specify): under: [ ] CCP 416.10 (corporation [] CCP 416.20 (defunct corporation) [] CCP 416.40 (association or partnership) [] other (specify): 4. by personal delivery on (date): WORKERS' COMPENSATION APPEALS BOARD [] [] [] CCP 416.60 (minor) CCP 416.70 (conservatee) CCP 416.90 (authorized person) American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE -- SPECIAL NOTICE OF LAWSUIT 1) I served the (check all that apply): a. [ ] Special Notice of Lawsuit [ ] Order Joining Party Defendant b. on defendant (name): c. Person served: [ ] Party in 1(b) [ ] Application for Adjudication of Claim [ ] Medical Records [ ] Claim Form [ ] Other (specify): [ ] Other (specify name and relationship to defendant): d. Address where the party was served: e. by delivery [ ] at home [ ] at business [ ] other (specify): (a) date: (b) time: (c) address: f. by mailing (1) date: (2) place: 2) Manner of service (check proper box) a. [ ] Personal service. By personally delivering copies (CCP 415.10) b. [ ] Substituted service on corporation, unincorporated association (including partnership), or public entity. By leaving, during usual office hours, copies in the office of the person served with the person who apparently was in charge and thereafter mailing (by first class mail, postage prepaid) copies to the person served at the place where the copies were left. [CCP 415.20(a)] c. [ ] Substituted service on natural person, minor, conservatee, or candidate. By leaving copies at the dwelling house, usual place of above, or usual place of business of the person served in the presence of a competent member of the household or a person apparently in charge of the office or place of business, at least 18 years of age, who was informed on the general nature of the papers, and thereafter mailing on (date)____________from (city)______________________or [ ] declaration of mailing attached (by first-class mail, postage prepaid) copies to the person served at the place where the copies were left. [CCP 415.20(b)] (Attach separate declaration or affidavit stating acts relied on to establish reasonable diligence in first attempting personal service.) d. [ ] Mail and acknowledgment service. By mailing (by first class mail or airmail, postage prepaid) copies to the person served, together with two copies of the form of notice and acknowledgment and a return envelope, postage prepaid, addressed to the sender. (CCP 415.30) (Attach completed acknowledgment of receipt.) e. [ ] Certified or registered mail service. By mailing to an address outside California (by first-class mail, postage prepaid, requiring a return receipt) copies to the person served. (CCP 415.40) (Attach signed return receipt or other evidence of actual delivery to the person served.) f. [ ] Other (specify code section): g. [ ] Additional page describing service is attached. 3) The "Notice to the Person Served" (on the Notice) was completed as follows (CCP 412.30, 415.0 and 474): a. [ ] as an individual defendant. b. [ ] as the person sued under the fictitious name of (specify): c. [ ] on behalf of (specify): under: [ ] CCP 416.10 (corporation [] CCP 416.60 (minor) [] CCP 416.20 (defunct corporation) [] CCP 416.70 (conservatee) [] CCP 416.40 (association or partnership) [] CCP 416.90 (authorized person) [] other (specify): 4) At the time of service I was at least 18 years of age and not a party to this action. 5) Fee for service: $ 6) Person serving: Name: Address: Telephone no.: a. [ ] Not a registered California process server. b. [ ] Exempt from registration under Bus. & Prof. Code 22350(b). c. [ ] Registered California process server: (i) [ ] Owner [ ] Employee [ ] Independent contractor (ii) Registration no.: (iii) County: d. [ ] California sheriff, marshal or constable. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. __________________________________________ (Signat