This information is provided free of charge by the Department of Industrial Relations from its web site at These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at

Chapter 8. Office of the Director
Subchapter 2.05. Enforcement of Workers' Compensation Coverage, Penalty Assessment Orders, Stop Orders and Posting and Notice Requirements
Article 6. Contents of Orders, of Direction to File Verified Statement and of Verified Statement

New Query

§15577. Verified Statement.

The verified statement, which shall be mailed to the employer by the Workers' Compensation Appeals Board simultaneously with the issuance of Findings of Fact, Findings and Order or Findings and Award, shall be found on the reverse side of the Direction to File Verified Statement and shall contain the following information:

(a) That the employer must complete the verified statement and submit the requested information to the Division.

(b) The number of employees in the employer's employ on the date of injury.

(c) A certification under penalty of perjury by the employer that such number is true and correct.

(d) The employer's signature, address and the date and place of execution thereof.

Go BackGo Back to Article 6 Table of Contents