STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR ADJUDICATION OF CLAIM Applicant (If other than Injured Worker) Injured Worker (Completion of this section is required) DWC/WCAB Form 1A (11/2008) - (Page 1) Venue choice is based upon (Completion of this section is required)Select 3 - Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet)WCAB1 Zip Code City Street Address2/PO Box (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) Name (Please leave blank spaces between numbers, names or words) SSN (Numbers Only) Case No. Amended Application 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).) Zip Code MI First Name Last Name Street Address/PO Box (Please leave blank spaces between numbers, names or words) Street Address2/PO Box (Please leave blank spaces between numbers, names or words) International Address (Please leave blank spaces between numbers, names or words) City State State Insurance Carrier Employer Lien Claimant IT IS CLAIMED THAT (Complete all relevant information): , while employed as a(n)1. The injured worker, born suffered a :Street Address/PO Box - Please leave blank spaces between numbers, names or words.Employer Information (Completion of this section is required) Insurance Carrier Information (If known and if applicable - include even if carrier is adjusted by claims administrator) Claims Administrator Information (If known and if applicable) (Choose only one)and ended onwhich began onWCAB1DWC/WCAB Form 1A (11/2008) - (Page 2) (DATE OF BIRTH: MM/DD/YYYY) (Date of injury: MM/DD/YYYY) Zip Code City Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) Employer Name (Please leave blank spaces between numbers, names or words) Insured Self-Insured Legally Uninsured Uninsured Zip Code State City Street Address/PO Box (Please leave blank spaces between numbers, names or words) Name (Please leave blank spaces between numbers, names or words) Zip Code City Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) Insurance Carrier Name (Please leave blank spaces between numbers, names or words) City The injury occurred at (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) (OCCUPATION AT THE TIME OF INJURY) specific injury cumulative injury State State, State Zip Code 4. The injury caused disability as follows:5. Compensation: Compensation was paid:6. Has the worker received any unemployment insurance benefits and/or any unemployment compensation disability benefits (state disability) since the date of injury?2. The injury occurred as follows: 3. Actual earnings at the time of injury:MM/DD/YYYYMM/DD/YYYYMM/DD/YYYYMM/DD/YYYYMM/DD/YYYY(State which parts of the body were injured)MM/DD/YYYYFirst Period of Disability:Second Period of Disability:WCAB1DWC/WCAB Form 1A (11/2008) - (Page 3) (EXPLAIN WHAT THE WORKER WAS DOING AT THE TIME OF INJURY AND HOW THE INJURY OCCURED) Rate of Pay $ Monthly Weekly Hourly State value of tips, meals, lodging, or other advantages, regularly received $ Number of hours worked per week Last day off work due to injury: Start Date End Date End Date Start Date Yes No Date of last payment: Yes No Total paid: Weekly rate(s): Monthly Weekly Hourly Body Part 1: Body Part 2: Body Part 3: Body Part 4: Other Body Parts: 8. Other cases have been filed for industrial injuries by this worker as follows:9. This application is filed because of a disagreement regarding liability for:Names and addresses of doctor(s)/hospital(s)/clinic(s) that treated or examined for this injury, but that were not provided or paid for by the employer or insurance carrier:Did Medi-Cal pay for any health care related to this claim? (NAME OF PERSON OR AGENCY PROVIDING OR PAYING FOR MEDICAL CARE)7. Medical treatment:Medical treatment was received:All treatment was furnished by the Employer or Insurance Carrier:Date of last treatment:WCAB1DWC/WCAB Form 1A (11/2008) - (Page 4) Yes No MM/DD/YYYY Yes No Other treatment was provided/paid by: Yes No Name of Doctor/Hospital/Clinic 1 (Please leave blank spaces between numbers, names or words) Name of Doctor/Hospital/Clinic 2 (Please leave blank spaces between numbers, names or words) Temporary disability indemnity Reimbursement for medical expense Medical treatment Compensation at proper rate Permanent disability indemnity Rehabilitation Supplemental Job Displacement/Return to Work Other (Specify) Case Number 2 Case Number 1 Case Number 4 Case Number 3 City, CaliforniaMM/DD/YYYYIs the Applicant Represented? Applicant Attorney/Representative SignatureApplicant Signature If "No", applicant is to sign and date below. If "Yes", applicants representative is to complete the following and is to sign and date below.WCAB1DWC/WCAB Form 1A (11/2008) - (Page 5) Yes No MI Dated at Date Zip Code City Law Firm or Company Name (If Applicable) Law Firm Number (If Applicable) Attorney/Representative Last Name Attorney/Representative First Name Law Firm/Attorney Non-Attorney Representative State Street Address/PO Box (Please leave blank spaces between numbers, names or words) INSTRUCTIONSFILING AND SERVICE OF A DECLARATION OF READINESS IS A PREREQUISITE TO THE SETTING OF A CASE FOR HEARING.Effect of Filing Application Filing of this application begins formal proceedings against the defendant(s) named in your application.Assistance in Filling Out Application You may request the assistance of an information and assistance officer of the Division of Workers' Compensation.Right to Attorney You may be represented by an attorney or agent, or you may represent yourself. The attorney's fee will be set by the Workers' Compensation Appeals Board at the time the case is decided and is ordinarily payable out of your award. Filling Out Application For "amended" applications, the venue choice must be the same as that specified on the original application, unless an order changing venue has issued. A street or P.O. Box address within the United States must be entered for the place where the injury occurred. Therefore, if the injury did not occur at a fixed or identifiable location (such as a field, a highway,or on water), or if the injury occurred outside of the United States, the employer's business address or another appropriate address must be specified; however, a short explanation regarding the place of injury may be appended to the application. If medical treatment has been paid for by Medi-Cal, Medicare, group health insurance, or a private carrier,please specify. Service of Documents Your attorney or agent will serve all documents in accordance with Labor Code section 5501 and the Workers' Compensation Appeals Board's Rules of Practice and Procedure. If you have no attorney or agent, copies of this application will be served by the Workers' Compensation Appeals Board on all parties. If you file any other document, you must mail or deliver a copy of the document to all parties in the case. IMPORTANT! If any applicant is under 18 years of age, it will be necessary to file a Petition for Appointment of Guardian ad Litem. Forms for this purpose may be obtained at the district office of the Workers' Compensation Appeals Board, or by calling the district office and requesting this form. WCAB1DWC/WCAB Form 1A (11/2008) - (Page 6)