WCAB Case No.: Worker: STATEMENT IN COMPLIANCE WITH LABOR CODE §4906(G) I, the undersigned, declare that I have complied with the requirements of Labor Code §4906(g), as follows: "The employee, the insurer, the employer, and the attorneys for each party shall sign and file with the Board a statement, with the application* or answer, under penalty of perjury that they have not violated section 139.3 and they have not offered, delivered, received, or accepted any rebate, refund, commission, preference, patronage, dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for any referred examination or evaluation." I declare under penalty of perjury the foregoing is true and correct. If signing on behalf of a corporation or other business entity, complete the following: I certify I have been given the authority by (Name of employer, carrier, etc.) to sign this declaration on its behalf. Typed or printed name of signer ________________________________ Signature Title (Attorney for Worker, etc.) * Includes Compromise and Release Agreement or Stipulation with Request for Award if an opening document. Executed on _____________________ at _______________________, California WC-006 2002 © American LegalNet, Inc.