STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION MINUTES OF HEARING Case No. Date of Hearing (MM/DD/YYYY) Hearing Information AT Before Trial Conf MSC EXP. HEARING Lien Request Date (MM/DD/YYYY) Applicant First Name MI Last Name VS Defendants Employer Name (Please leave blank spaces between numbers, names or words) Appearances Applicant Present Attorney Hearing Rep Not Present Applicant Represented By Defendant Represented By Others Appearing Cert. No. Interpreter Party Making Request Joint Request For: Applicant Defendant Continuance OTOC Other Request By: Position of Opposing Party Agree Oppose Unreachable DWC-CA form 10245 (11/2008) ( Page 1 ) Unknown Letter Telephone Reason For Request Applicant: Illness Applicant Now Represented Applicant Requests Representation Applicant: Vacation Calendar Conflict: Applicant Calendar Conflict: Defense Calendar Conflict: Lien Claimant Defense: Vacation Change of Circumstances Consolidation Dispute Resolved by Agreement Further Discovery: Def Med Further Discovery: App Med Further Discovery: AME Improper/Insufficient Notice by Party Non Appearance: Applicant Non Appearance: Defense Non Appearance: Witness Settlement Pending Unavailability of Witnesses: Defense Further Discovery: Depo New Application Joinder Defense: Illness No Issues Pending Non Appearance: Lien Claimant Unavailability of Witnesses: Applicant Venue Board Reason Arbitration Bankruptcy Pending Insufficient Time to Finish Service Defective Defective Notice Interpreter Not Available UEF Issues Insufficient Time to Start Recusal Reporter Not Available WCJ Not Available Other/ Comments Good Cause Appearing, It is Ordered That the Request For Continuance Granted Days For Continuance Denied C&R DWC-CA form 10245 (11/2008) ( Page 2 ) OTOC Granted STIPS OTOC Denied OTOC Decision OTOC C&R / STIPS Submitted for Approval LIEN STIPS and ORDER Approved MSC CONF C&R / STIPS Approved N.O.I. to Allow/Disallow Issued TRIAL LIEN TRIAL CONTD TESTIMONY At Set On MM/DD/YYYY Location Before Judge Supplemental Pages Attached Date - MM/DD/YYYY Notice To Served on parties and lien claimants present DWC-CA form 10245 (11/2008) ( Page 3 ) Pages WORKERS' COMPENSATION ADMINSTRATIVE LAW JUDGE Pursuant to Rule 10500 you are designated to serve this/these document(s) on all parties. SUPPLEMENT TO MINUTES OF HEARING/ORDER/ORDER AND DECISION ON REQUEST FOR CONTINUANCE/ORDER TAKING OFF CALENDAR / NOTICE OF HEARING HEARING DATE MM/DD/YYYY Comment/Discussion/Motion Order(s) Served with the Minutes of Hearing WORKERS' COMPENSATION ADMINSTRATIVE LAW JUDGE DWC-CA form 10245 (11/2008) ( Page 4 )