Stipulation And Order To Pay Lien Claimant {WC-904}

STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION Case No. Applicant STIPULATION vs. AND ORDER TO PAY LIEN CLAIMANT Defendants. Lien Claimant a lien dated in the sum of $ The parties hereto agree to accept the sum of $ and satisfaction of the above claim, payable by The basis for said lien was services provided as follows: Medical-legal Self-procured treatment Other has filed . as full payment . (LIEN CLAIMANT) (PAYOR) (DATE) (DATE) Pursuant to the stipulation above, IT IS SO ORDERED THE AMOUNT BE PAID WITHIN TWENTY (20) DAYS. Notice to: Pursuant to Rule 10500, you are designated to serve the attached document(s) forthwith on all parties shown on the Official Address Record along with a proof of service. You shall maintain the proof of service, which shall not be filed with the W.C.A.B. unless a dispute arises regarding service of the document. Date: By: WORKERS' COMPENSATION JUDGE WC-904 American LegalNet, Inc. www.FormsWorkFlow.com