The statement, which shall be mailed to the employer by the Workers' Compensation Appeals Board simultaneously with the issuance and service of Findings of Fact, Findings and Order or Findings and Award, shall contain the following information:
(a) The Workers' Compensation Appeals Board has found the employer to be without the required workers' compensation coverage.
(b) The Division shall assess the employer a penalty of one hundred ($100) dollars or five hundred ($500) dollars per employee at the time of the injury pursuant to Labor Code Sections 3710.1 and 3722, respectively.
(c) The employer is requested to complete and submit to the Division within ten (10) days the verified statement on the reverse side of the Direction to File Verified Statement indicating the number of employees employed on the date of injury.
(d) The Division may dispute the accuracy of such verified statement.
(e) The Appeal procedure for objecting to the one hundred ($100) dollar injury-related Penalty Assessment Order (Labor Code Section 3710.1) and to the five hundred ($500) dollar injury-related Penalty Assessment Order (Labor Code Section 3722).
NOTE: Authority cited: Sections 55 and 3710, Labor Code. Reference: Sections 3700, 3710, 3710.1, 3710.2, 3711, 3712, 3713, 3714, 3718, 3722, 3723, 3725, 3726 and 3727, Labor Code.