State of California Division of Workers' Compensation Retraining and Return to Work Unit NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK For injuries occurring on or after 1/1/04 DWC - AD 10133.53 THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR (All information in this section must be completed): Claims Administrator Type: (Please Choose One) Third Party Administrator Insurance Company Employer Employer (name of firm) is offering you (Employee name) the position of a . Name of Job You may contact Date of offer: concerning this offer. Phone No.: Date job starts: MM/DD/YYYY MM/DD/YYYY Claims Administrator Claim Number : NOTICE TO EMPLOYEE (All information in this section must be completed) Name of employee: First Name (Choose only one) a specific injury on Last Name MM/DD/YYYY and ended on a cumulative trauma injury which began on (END DATE: MM/DD/YYYY) (START DATE: MM/DD/YYYY) Date offer received: Date of Birth: MM/DD/YYYY MM/DD/YYYY You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work. Regardless of whether you accept or reject this offer, the remainder of your permanent disability payments may be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you will not be entitled to the supplemental job displacement benefit unless: Modified Work or Alternative Work A. You cannot perform the essential functions of the job; or B. The job is not a regular position lasting at least 12 months; or C. Wages and compensation offered are less than 85% paid at the time of injury; or D. The job is beyond a reasonable commuting distance from residence at time of injury. DWC-AD form 10133.53 (SJDB) Rev: 11/2008 - Page 1 AD10133.53 POSITION REQUIREMENTS (All information in this section must be completed) Actual job title: Wages: $ Per hour Week Month Is salary of modified/alternative work the same as pre-injury job? Yes No Is salary of modified/alternative work at least 85% of pre-injury job? Yes No Will job last at least 12 months? Yes No Is the job a regular position required by the employer's business? Yes No Work location: Duties required of the position: Description of activities to be performed (if not stated in job description): DWC-AD form 10133.53(SJDB) Rev: 11/2008 - Page 2 AD10133.53 Physical requirements for performing work activities (include modifications to usual and customary job): Name of doctor who approved job restrictions (optional): Date of report: MM/DD/YYYY Date of last payment of Temporary Total Disability: MM/DD/YYYY Preparer's Name: Preparer's Signature: Date: MM/DD/YYYY THIS SECTION TO BE COMPLETED BY EMPLOYEE (All information in this section must be completed) I accept this offer of Modified or Alternative work. I reject this offer of Modified or Alternative work and understand that I am not entitled to the Supplemental Job Displacement Benefit. I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the Supplemental Job Displacement Benefit. Signature: Date: MM/DD/YYYY I feel I cannot accept this offer because: DWC-AD form 10133.53(SJDB) Rev: 11/2008 - Page 3 AD10133.53 NOTICE TO THE PARTIES If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee. The employer or claims administrator must forward a completed copy of this agreement to the Administrative Director within 30 days of acceptance or rejection. (Retraining and Return to Work, Division of Workers’ Compensation, P.O. Box 420603, S.F., CA 94142-0603) If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director. DWC-AD form 10133.53(SJDB) Rev: 11/2008 - Page 4 AD10133.53