STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD STIPULATIONS WITH REQUEST FOR AWARD Date of Injury Case No. MM/DD/YYYY SSN (Numbers Only) Venue Choice is based upon: (Completion of this section is required) County of residence of employee (Labor Code section 5501.5(a)(1) or (d).) County where injury occurred (Labor Code section 5501.5(a)(2) or (d).) County of principal place of business of employee's attorney (Labor Code section 5501.5(a)(3) or (d).) Select 3 Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet) Applicant (Completion of this section is required) First Name MI Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) City Employer #1 Information (Completion of this section is required) Insured Self-Insured Legally Uninsured State Zip Code Uninsured Employer Name (Please leave blank spaces between numbers, names or words) Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code DWC-CA form 10214 (a) Page 1 (Rev 11/2008) Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Claims Administrator Information (if known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Employer #2 Information (Completion of this section is required) Insured Self-Insured Legally Uninsured Uninsured Employer Name (Please leave blank spaces between numbers, names or words) Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) State Zip Code Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code DWC-CA form 10214 (a) Page 2 (Rev 11/2008) Claims Administrator Information (if known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City Employer #3 Information (Completion of this section is required) Insured Self-Insured Legally Uninsured State Zip Code Uninsured Employer Name (Please leave blank spaces between numbers, names or words) Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) State Zip Code Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) City Claims Administrator Information (if known and if applicable) State Zip Code Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code DWC-CA form 10214 (a) Page 3 (Rev 11/2008) Employer #4 Information (Completion of this section is required) Insured Self-Insured Legally Uninsured Uninsured Employer Name (Please leave blank spaces between numbers, names or words) Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) Zip Code Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Claims Administrator Information (if known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code The parties hereto stipulate to the issuance of an Award and/or Order, based upon the following facts, and waive the requirements of Labor Code section 5313: 1. Employees First Name , Employees Last Name birth date MM/DD/YYYY , while employed at , State as a(n) Occupation DWC-CA form 10214 (a) Page 4 (Rev 11/2008) , Group in More than 4 Companion Cases Specific Injury Case Number 1 (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Cumulative Injury Body Part 1: Body Part 4: Body Part 2: Other Body Parts: Specific Injury Body Part 3: Case Number 2 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 4: Body Part 2: Other Body Parts: Specific Injury Body Part 3: Case Number 3 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 4: Body Part 2: Other Body Parts: Specific Injury Body Part 3: Case Number 4 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 4: Body Part 2: Other Body Parts: Body Part 3: by the employer(s) and their insurer(s) listed above and who sustained injury(ies) arising out of and in the course of employment to (Please list all body parts injured) DWC-CA form 10214 (a) Page 5 (Rev 11/2008) 2. The injury (ies) caused temporary disability for the period MM/DD/YYYY through per week. Indemnity Paid for which indemnity has been paid at $ MM/DD/YYYY 2(a).The injury(ies) caused additional temporary disability for the period MM/DD/YYYY through MM/DD/YYYY at the rate of $ Rate in the amount of $ Indemnity Paid 3. The injury(ies) caused permanent disability of per week beginning MM/DD/YYYY % for which indemnity is payable at $ Indemnity Rate in the sum of $ And a life pension of $ Life Pension , less credit for such payments previously made. per week thereafter. Labor Code §4658(d) adjustment: Increase rate to $ as of MM/DD/YYYY Decrease rate to $ as of MM/DD/YYYY Not Ap