Application For Discretionary Payments From The Uninsured Employers Fund {DWC-UEF 50}

APPLICATION FOR DISCRETIONARY PAYMENTS FROM THE UNINSURED EMPLOYERS' FUND Applicant (Completion of this section is required) Prompt consideration of your application requires COMPLETE and FULL ANSWERS TO ALL THE QUESTIONS appearing below1. EmployerDWC / UEF 50 Rev: 11/2008 - Page 1 StateUEF50Uninsured Employers Benefit Trust Fund Case Number SSN (Numbers Only) Zip Code City Street Address2/PO Box (Please leave blank spaces between numbers, names or words) Street Address1/PO Box (Please leave blank spaces between numbers, names or words) Last Name First Name Office Address /PO Box (Please leave blank spaces between numbers, names or words) City Zip CodeCA Zip Code City Street Address1/PO Box (Please leave blank spaces between numbers, names or words) Name Street Address2/PO Box (Please leave blank spaces between numbers, names or words) MI State State 4. Have you returned to work ?5. Have you received payments from anyone for this injury ?I, the undersigned, hereby apply for discretionary payments of compensation from the Uninsured Employers Fund under Laber Code section 4903.3 and declare under penalty of perjury that the information furnished above is true and correct to the best of my knowledge and belief. I hereby authorize any doctors or hospitals that have treated me for this injury to furnish and disclose all facts concerning my medical condition that are within their knowledge, and to allow inspection of and provide copies of any records concerning my medical condition that are under their control.Executed on,at , California ( Signature of Applicant )(Choose only one)2. Please specify a specific injury date or specify if it was a cumulative trauma injury:(MM/DD/YYYY) (MM/DD/YYYY)DWC / UEF 50 Rev: 11/2008 - Page 2UEF50 (End Date: MM/DD/YYYY)and ended on (Start Date: MM/DD/YYYY) (DATE OF INJURY: MM/DD/YYYY) as specific Injury on a cumulative trauma which began on 3. List the names and address of doctors and hospitals that have treated you for this injury: If Yes, give date Yes No If Yes, how much were you paid ? $ Yes No Who paid you ?