Application For Subsequent Injuries Fund Benefits

STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITS Case Number 1 Case Number 4 Case Number 2 Case Number 5 Case Number 3 Injured Worker First Name MI Last Name VS Employer Name Insurance Carrier Name Third Party Administrator APPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITS 1. Applicant , born on MM/DD/YYYY was injured on MM/DD/YYYY , as a at per California, with earnings of $ Applicant sustained injury arising out of and occurring in the course of his/her employment resulting in permanent and partial disability affecting the following parts of the body: The permanent disability, when considered alone and without regard to or adjustment for the applicant's occupation or age is equal to percent or more of total disability. Application for SIF Benefits - Version 11/2008 APPSIF 2. Immediately prior to the injury, applicant was permanently disabled in the following respects The pre-existing disabilities occurred as a result of: 3. Applicant has previously filed a workers' compensation claim with the Workers' Compensation Appeals Board Case Number 4. Applicant filed for Social Security Disability benefits on and is receiving $ per month. Applicant's Social Security Number is WHEREFORE, applicant requests benefits as provided by law Attorney for Applicant Signature Applicant Signature Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Application for SIF Benefits - Version 11/2008 APPSIF