Application For Adjudication Of Claim (Death Cases) {DIA 2}

DIA WCAB Form 2, APPLICATION FOR ADJUDICATION OF CLAIM (Death Case). This form is used by the California Division of Workers' Compensation to initiate the process of adjudicating claims related to death benefits. Filing of this application begins formal proceedings against the defendants named in your application. You may request the assistance of an information and assistance officer of the Division of Workers' Compensation. You may be represented by an attorney or agent, or you may represent yourself. The attorney fee will be set by DWC judge at the time the case is decided and is ordinarily payable out of your award. All blanks in the application shall be completed. Where the information is unknown, place "unknown" in the blank. If medical treatment is paid for by Medi-Cal, Medicare, group health insurance or private carrier, please specify. www.FormsWorkflow.com