STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD Case No. (IF APPLICATION HAS BEEN FILED, CASE NUMBER MUST BE INDICATED REGARDLESS OF DATE OF INJURY) vs. Claimant/Applicant Employer/Insurance Carrier/Defendant SUBPOENA The People of the State of California Send Greetings to: YOU ARE HEREBY COMMANDED to appear before a Workers' Compensation Judge of the WORKERS' COMPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA at on the entitled action. day of , , at o'clock M., to testify in the above- For failure to attend as required, you may be deemed guilty of contempt and liable to pay to the parties aggrieved all losses and damages sustained thereby and forfeit one hundred dollars in addition thereto. This subpoena is issued at request of , Telephone No. WORKERS' COMPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA Secretary, Assistant Secretary, Workers' Compensation Judge Date , This subpoena does not apply to any member of the Highway Patrol, Sheriff's Office or city Police Department unless accompanied by notice from the Board that deposit of the witness fee has been made in accordance with Government Code 68097.2, et seq. FOR INJURIES OCCURRING ON OR AFTER JANUARY 1, 1990 AND BEFORE JANUARY 1, 1994: If no Application for Adjudication of Claim has been filed, a declaration under penalty of perjury that the Employee's Claim for Workers' Compensation Benefits (Form DWC-1) has been filed pursuant to Labor Code Section 5401 must be executed properly. [SUBPOENA INVALID WITHOUT DECLARATION] DIA WCAB 30 (Side 1) (Rev. 06/94) American LegalNet, Inc. www.USCourtForms.com DECLARATION FOR INJURIES OCCURRING ON OR AFTER JANUARY 1, 1990 AND BEFORE JANUARY 1, 1994, FOR WHICH AN APPLICATION FOR ADJUDICATION OF CLAIM HAS NOT BEEN FILED STATE OF CALIFORNIA, County of Case No. The undersigned states: That he/she is (one of) the attorney(s) of record/representative(s) for the applicant/defendant in the action captioned on the reverse hereof, and that an Employee's Claim for Workers' Compensation Benefits (DWC Form 1) has been filed in accordance with Labor Code Section 5401 and California Code of Regulations, title 8, section 10120 (Administrative Director's Rules and Regulations), by the alleged injured worker in this action, or, if the worker is deceased, by the dependent(s) of the decedent, and that a true copy of the form filed is attached hereto. I declare under penalty of perjury that the foregoing is true and correct. Executed on , , at , California. Signature Address Telephone DECLARATION OF SERVICE STATE OF CALIFORNIA, County of I, the undersigned, state that I served the foregoing Subpoena by showing the original and delivering a true copy thereof, together with a copy of the Declaration in support thereof, to each of the following named persons, personally, at the date and place set forth opposite each name. Date Name of Person Served Place I declare under penalty of perjury that the foregoing is true and correct. Executed on , , at , California. Signature DIA WCAB 30 (Side 2) (Rev. 06/94) American LegalNet, Inc. www.USCourtForms.com