State of California Division of Workers' Compensation Workers' Compensation Appeals Board Arbitration Submittal Form Employee First Name: Middle Initial: Last Name: Address/P.O. Box: City: State: Employee Representative Law Firm /Attorney Zip Code: Non attorney Representative Law Firm or Company Name (If applicable): First Name: Middle Initial: Last Name: Address/P.O.Box: City: State: Zip Code: Is the injured worker requesting arbitration or is the injured worker a party to the arbitration? List all the parties to this request for arbitration in the spaces provided below. Party Requesting Arbitration (If applicable) Insurance Co. Self-insured Legally Uninsured Uninsured Lien Claimant Case number: Party Name: Address: City: State: Zip Code: Party Representative Law Firm or Company Name (If applicable) First Name: Middle Initial Last Name: Address/P.O.Box: City: DWC-CA form 10297 Page 1 of 4 State: Zip Code: Party to the Arbitration Insurance Co. Self-insured Legally Uninsured Uninsured Lien Claimant Case Number: Party Name: Address: City: Party Representative State: Law Firm /Attorney Zip Code: Non attorney Representative Law Firm or Company Name (If applicable): First Name: Middle Initial: Last Name: Address/P.O.Box: City: Party to the Arbitration Insurance Co. Self-insured State: Legally Uninsured Uninsured Zip Code: Lien Claimant Case Number: Party Name: Address: City: Party Representative State: Law Firm /Attorney Zip Code: Non attorney Representative Law Firm or Company Name (If applicable) First Name: Middle Initial: Last Name: Address/P.O.Box: City: DWC-CA form 10297 Page 2 of 4 State: Zip Code: Party to the Arbitration Insurance Co. Self-insured Legally Uninsured Uninsured Lien Claimant Case Number: Party Name: Address: City: State: Law Firm /Attorney Party Representative Zip Code: Non attorney Representative Law Firm or Company Name (If applicable): First Name: Middle Initial: Last Name: Address/P.O.Box: City: State: Zip Code: Party to the Arbitration Insurance Co. Self-insured Legally Uninsured Uninsured Lien Claimant Case Number: Party Name: Address: City: Party Representative State: Law Firm /Attorney Zip Code: Non attorney Representative Law Firm or Company Name (If applicable): First Name: Middle Initial: Last Name: Address/P.O.Box: City: DWC-CA form 10297 Page 3 of 4 State: Zip Code: The issues below are hereby submitted for arbitration pursuant to Labor Code section 5275: Mandatory arbitration under Labor Code section 5275 (a) Insurance Coverage Contribution Voluntary arbitration under Labor Code section 5275 (b) Explanation of issues submitted for arbitration The parties have agreed to have this case heard before: Arbitrator Name Address: City: State: Zip Code: Phone Number: The parties have unsuccessfully attempted to agree on a arbitrator and request a list of arbitrators pursuant to Labor Code section 5271(b). The parties to the arbitration must sign this form in the spaces provides below. Dated: at Party or party representative: Party or party representative: Party or party representative: Party or party representative: Party or party representative: DWC-CA form 10297 Page 4 of 4 , California on