Request For Dispute Resolution Before Administrative Director
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Request For Dispute Resolution Before Administrative Director Form. This is a California form and can be use in EAMS Forms Workers Comp.
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Tags: Request For Dispute Resolution Before Administrative Director, DWC-AD 10133.55 (SJDB), California Workers Comp, EAMS Forms
State of California
Division of Workers' Compensation
Retraining and Return to Work Unit
REQUEST FOR DISPUTE RESOLUTION
BEFORE ADMINISTRATIVE DIRECTOR
DWC - AD 10133.55
Original
Response
Employer Accepted Claim
Liability found by WCAB
More than 60 Days Since TTD Ended
Claim Number
Has PPD been stipulated, issued/ approved
Case Number
SSN (Numbers Only)
Employee (All information in this section must be completed)
First Name
MI
Last Name
Street Address /PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
DOB
Phone
MM/DD/YYYY
(Choose only one)
a specific injury on
MM/DD/YYYY
and ended on
a cumulative trauma injury which began on
(START DATE: MM/DD/YYYY)
DWC-AD form 10133.55 (SJDB) Rev: 11/2008 - ( Page 1)
(END DATE: MM/DD/YYYY)
10133.55
Employee Representative (If Applicable)
Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
Phone
Employer (All information in this section must be completed)
Insured
Self-Insured
Legally Uninsured
Uninsured
Name
Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
State
Zip Code
State
Zip Code
Phone
Employer Representative (if known and If applicable)
Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City
Phone
Claims Administrator Information (if known and if applicable)
Name (Please leave blank spaces between numbers, names or words)
Street Address/PO Box (Please leave blank spaces between numbers, names or words)
City
DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 2)
10133.55
Vocational & Return to Work Counselor (if applicable)
Name
Firm Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
State
City
Zip Code
Phone
Administrative Director Requested to resolve the following dispute because the parties disagree on (All information in
this section must be completed):
Employee's entitlement to a voucher.
The parties dispute the amount of the voucher.
The insurer has failed to pay training provider per title 8, California Code of Regulations sections 10133.57 and 10133.
58, and/or the VRTWC per title 8 California Code of Regulations sections 10133.57 and 10133.59.
The employee objects to the new job duties provided by the employer.
The employer objects to the amount of reimbursement approved or denied.
Other
Summary of informal efforts to resolve dispute
Requester Name
Date
Signature
DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 3)
MM/DD/YYYY
10133.55
