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Filling out the Workers' Compensation Appeals Board form correctly is crucial for ensuring that all claims and requests for allowances are processed efficiently. This guide will provide you with the necessary steps to complete the form online with clarity and confidence.

Follow the steps to successfully complete your form submission.

1. Click the ‘Get Form’ button to retrieve the Workers' Compensation Appeals Board form and open it in your editing environment.
2. Begin by entering the details of the injured worker, including their name, address, and social security number. Ensure that the information is accurate and typed clearly.
3. Provide the date of the claimed injury and the ID or case number associated with the claim.
4. Next, fill in the employer's information, including the name and address. If applicable, include details of the insurance carrier or the self-insurance certificate name along with the address where the claim is administered.
5. In the section pertaining to the lien claimant, input the name, address, and telephone number. If the lien claimant has an attorney, also provide the attorney's name and contact information.
6. Specify the amount you are requesting as a lien and the purpose of the lien claim by marking the appropriate box, indicating whether it is related to medical treatment, living expenses, or other specified costs.
7. Attach the required itemized statement justifying the lien as per the provided instructions.
8. If applicable, include the declaration under penalty of perjury regarding the Employee’s Claim for Workers’ Compensation Benefits. Ensure any supporting documents are mailed or delivered to all necessary parties.
9. Obtain the necessary signatures, including the lien claimant, attorney for the lien claimant, and the injured worker, along with the accompanying date.
10. Once all sections are completed, review the form for completeness and accuracy. You can then save your changes, download the completed form, print it, or share it as needed.

Submit your completed documents online to ensure timely processing of your claims.