STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD DECLARATION OF READINESS TO PROCEED NOTICE: Any objection to the proceedings requested by a Declaration of Readiness to proceed shall be filed and served within ten (10) days after service of the Declaration. Case No. Applicant First Name MI Last Name Employer Information VS 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 Declarants: Please designate your role (Please Select Only One) Employee Applicant Defendant State Zip Code Lien Claimant Declarant requests: (Please Select Only One) Mandatory Settlement Conference Lien Conference At the present time the principal issues are: (Check all that apply) Compensation Rate Permanent Disability Employment Rehabilitation/SJDB Future Medical Treatment Other Temporary Disability AOE/COE Self-Procured Medical Treatment Discovery Status Conference Rating MSC* Priority Conference Declarant relies on the report(s) of: Doctors (s) date MM/DD/YYYY *For a Rating MSC, all ratable medical reports, including treating physician, QME and AME reports, must be filed with this Declaration of Readiness, unless they have been previously filed. A Rating MSC will be set only where the issues are limited to permanent disability and the need for future medical treatment. DWC-CA form 10250.1 Page 1 (Rev. 6/2011) DWC-CA form 10250.1 Declarant states under penalty perjury that he or she is presently ready to proceed to hearing on the issues below and has made the following specific, genuine, good faith efforts to resolve the dispute(s) listed below: Unless a status or priority conference is requested, I have completed discovery on the issues listed above, and that all medical reports in my possession or control have been filed and served as required by the rules promulgated by the Court Administrator. Copies of this Declaration have been served this date as shown on the attached proof of service. Declarant's Signature Name of declarant or name of the law firm of the declarant (Print or Type) Address (Please leave blank spaces between numbers, names or words) Date Phone Number MM/DD/YYYY DWC-CA form 10250.1 Page 2 (Rev. 6/2011) DWC-CA form 10250.1 INSTRUCTIONS 1. This Declaration must be completed and filed before any case will be set for hearing at the request of any party. A party may request a mandatory settlement conference hearing, status conference hearing, rating mandatory settlement conference hearing, priority conference hearing or a lien conference. A mandatory settlement conference is held to assist the parties in resolving the dispute. If the dispute cannot be resolved at that time, the parties should be ready to frame issues, record stipulations, list exhibits, and list the witnesses who will testify at trial. A trial is set only at the discretion of the judge and is set for the purpose of receiving evidence. A rating mandatory settlement conference is a mandatory settlement conference but ratings of the medical reports will be available at the time of the conference. A status conference is not a mandatory settlement conference but a proceeding for which judicial attention is required. It can include, but is not limited to, a conference in a complicated case in which discovery is not complete and the parties need the judge's guidance. A priority conference is a conference held under Labor Code section 5502(c) in which the injured worker is represented by an attorney and the issues include employment and/or injury arising out of and in the course of employment. A lien conference is a proceeding for which judicial attention is required to resolve disputes on liens. If the dispute cannot be resolved at that time, the parties should be ready to frame issues, record stipulations, list exhibits, and list the witnesses who will testify at trial. 2. A lien claimant may file a declaration of readiness to proceed only after the underlying case has been resolved or where the applicant chooses not to proceed with his or her case. (Labor Code § 4903.6 (b).) A declaration of readiness filed by a lien claimant shall be accompanied by the verification required by section 10770.6 of title 8 of the California Code of Regulation. The failure to attach the verification or an incorrect verification may be a basis for sanctions. 3. Unless notified otherwise, no witness other than the applicant need attend conference hearings. Claims adjusters and lien claimants must be present or available by telephone. 4. The party requiring an interpreter must arrange for the presence of an interpreter, except that the defendant(s) must arrange for the presence of the interpreter if the injured worker is not represented by an attorney. 5. Continuances are not favored and none will be granted after the filing of this Declaration without a clear and timely showing of good cause. 6. The Workers' Compensation Appeals Board favors the presentation of medical evidence in the form of written reports. Workers' Compensation Information and Assistance - 1 (800) 736-7401 DWC-CA form 10250.1 Page 3 (Rev. 6/2011) DWC-CA form 10250.1