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Get Ca E3067 2010-2024

Nd ID & Password at: www.statefundca.com/statecontracts or fax to the Customer Service Center at 800-371-5905 Fatality Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. E M P L O Y E R 1a. AGENCY CODE OR SCIF POLICY NUMBER 2. MAILING ADDRESS (Number and Street, City, Zip) 2a. Phone Number 3. LOCATION, if different.

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