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DURABLE POWER OF ATTORNEY FOR HEALTH CARE (California Probate Code Section 4771) WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT WHICH IS AUTHORIZED BY THE KEEN HEALTH
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How to fill out wcab ca form 102501_ver7-2010
01
The first step in filling out wcab ca form 102501_ver7-2010 is to enter your personal information. This includes your name, address, phone number, and email address.
02
Next, you will need to provide details about your employer. This includes the name of the company, address, and contact information.
03
In section 3 of the form, you will need to provide information about your injury or illness. This includes the date it occurred, a description of what happened, and the body parts affected.
04
Section 4 requires you to provide information about your employment history. This includes the dates you were employed by the company, your job title, and a brief description of your job duties.
05
In section 5, you will need to provide information about any prior injuries or conditions that may be related to your current claim.
06
If you have any witnesses who can support your claim, you will need to include their names and contact information in section 6.
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Section 7 is where you will need to provide information about any medical treatment you have received for your injury or illness. This includes the names of the healthcare providers, the dates of treatment, and a brief description of the treatment received.
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Finally, you will need to sign and date the form in section 8, acknowledging that the information provided is true and accurate to the best of your knowledge.
Who needs wcab ca form 102501_ver7-2010?
01
Employees who have sustained a work-related injury or illness in California.
02
Employers who have received a claim from an employee for a work-related injury or illness.
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Workers' compensation attorneys who are representing either the employee or the employer in a workers' compensation claim.
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