«FIRM:addressblock»

STATE OF CALIFORNIA

WORKERS' COMPENSATION APPEALS BOARD

«APPLICANT:Contact.first_name» «APPLICANT:Contact.last_name», Applicant, v. «PARTY:Employer.Contact.Company.name»; «PARTY:Carrier.Contact.Company.name» Defendants. _______________________________/	EAMS No.: «INJURY:eams_case_number»

Dated: Click here to enter a date.	Respectfully submitted,

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«CASEFILE:AttorneyResponsible.Contact.fir» «CASEFILE:AttorneyResponsible.Contact.las»

Attorney for Applicant