California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 2 - Workers' Compensation Appeals Board-Rules and Practice Procedure
Article 16 - Liens
Section 10874 - Verification to Filing of Declaration of Readiness to Proceed by or on Behalf of Lien Claimant

The declarant shall make a diligent search to determine that the injured worker has chosen not to proceed with their case and the verification shall specify the efforts made in conducting the diligent search. A diligent search shall include contacting the injured worker, contacting the employer or carrier, or inquiring at the district office with appropriate venue pursuant to Labor Code section 5501.5(a)(1) or Labor Code section 5501.5(a)(2).

The verification shall be in the following form:

I declare under penalty of perjury under the laws of the State of California that:

[ ] The Declaration of Readiness to Proceed is not being filed because of a dispute subject to the independent medical review and/or independent bill review process; or

[ ] A timely petition appealing the Administrative Director's determination regarding independent medical review and/or independent bill review has been filed (Check one box); and

[ ] The underlying case has been resolved; or

[ ] At least six months have elapsed from the date of injury and the injured worker has chosen not to proceed with their case (Check one box). In determining that the injured worker has chosen not to proceed with their case, I have made a diligent search consisting of the following efforts (specify):

- ______________________ s/s ____________________ on _ ___________________________

Failure to attach the verification or an incorrect verification may be a basis for sanctions.