STATE OF CALIFORNIA
Department of Industrial Relations
Division of Workers' Compensation
WORKERS' COMPENSATION APPEALS BOARD
A decision was filed in the above-entitled case on ___________________________________________.
The ___________________________________________________________ is aggrieved by said
decision and hereby petitions for reconsideration upon the following grounds: (strike out items not
1. By the order, decision or award, the Board acted without or in excess of its powers.
2. The order, decision, or award was procured by fraud.
3. The evidence does not justify the findings of fact.
4. Petitioner has discovered new evidence material to him which he could not with reasonable diligence
have discovered and produced at the hearing.
5. The findings of fact do not support the order, decision or award.
In support of the above, petitioner gives the following details, including a statement of facts upon which
petitioner relies and a discussion of the law applicable thereto:
DWC/WCAB Form 45 (Page 1) (Rev 3-76)
WHEREFORE, Petitioner requests that reconsideration be granted; that further proceedings be
had; and that decision be made to give petitioner all the benefits to which he is entitled under the
Labor Code of the State of California, including the relief requested herein.
Attorney for Petitioner
STATE OF CALIFORNIA )
County of ________________ )
I, the undersigned, say that I am _____________________________________________
in the above-entitled action. I have read the foregoing petition for reconsideration and know the
contents thereof, and that the same is true of my own knowledge, except as to