STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD ANSWER TO APPLICATION FOR ADJUDICATION OF CLAIM Case Number (Choose only one) a specific injury on (MM/DD/YYYY) a cumulative trauma injury which began on (START DATE: MM/DD/YYYY) and ended on (END DATE: MM/DD/YYYY) Name(s) of Answering Party(ies) (Please leave blank paces between names, numbers or words) Injured Worker Last Name MI First Name Employer Information 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 Zip Code Insurance Carrier Information (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 DWC/ WCAB Form 10 (Page 1) (REV. 11/2008 ) State Zip Code WCAB10 Claims Administrator Information (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 ANSWERING DEFENDANTS deny the allegations of the application as indicated below with such explanations as expressly set forth and admit all other material allegations. DENIALS (Mark X if allegation is denied) Employment EXPLAIN BELOW Occupation Injury (IF DENIAL IS BASED ON DATE OR PART OF BODY INJURED, EXPLAIN FULLY) Insurance coverage (STATE IF EMPLOYER HAS BEEN NOTIFIED TO APPEAR AND DEFEND) Liability for self-procured treatment Liability for future medical treatment Medical-legal costs Earnings DWC/ WCAB Form 10 (Page 2) (REV. 11/2008 ) WCAB10 Periods of disability (GIVE LAST DAY WORKED AND CORRECT DATE OF RETURN TO WORK, IF ANY) Rehabilitation Supplemental job displacement / return to work Permanent disability (IF APPORTIONMENT IS CLAIMED, SO STATE) IT IS FURTHER ALLEGED: 1. Defendants have paid disability indemnity in the total amount of $ a week beginning MM/DD/YYYY at the rate of $ plus MM/DD/YYYY through 2. Affirmative defenses and other matters : The Answer to this Application is being filed on behalf of (Please check one only) Employer Insurance Carrier Both Defendant(s) do(es) not waive the right to raise additional issues in accordance with the provisions of law and the Rules of Practice and Procedure if other issues develop. Dated: Phone Number Signature Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City DWC/ WCAB Form 10 (Page 3) (REV. 11/2008 ) State Zip Code WCAB10