5)) County of last active employee of employee's attorney (Labor Code section 5501.5(a)(6) or (d)) County of last employer of employee's attorney (Labor Code section 5501.5(a)(7) or (d)) County of employer where employee was last employed (Labor Code section 5501.5(a)(7) or (d)) State where injury occurred (Labor Code section 5501.5(a)(2) or (d)). [Signed] M.F.J.T., J.L., M.H.P., T.D.E., R.M.D., E.R., J.O.F., R.H.P., A.
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Reset Form Print Form STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD STIPULATIONS WITH REQUEST FOR AWARD (Death Case) Case Number 1 Case Number 2 Venue Choice
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