State of California Division of Workers' Compensation Retraining and Return to Work Unit Request for Reimbursement of Accommodation Expenses For injuries on or after July 1, 2004 DWC - AD 10120 Employer (All information in this section must be completed) Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Employee Information Employee First Name Employee Last Name Claim Number Job Title (at the time of injury) Job Duties (attach job description if available): Date of Birth: MM/DD/YYYY (Choose only one) a specific injury on MM/DD/YYYY a cumulative trauma injury which began on and ended on (START DATE: MM/DD/YYYY) DWC-AD form 10120 (SJDB) Rev: 11/2008 - (Page 1) (END DATE: MM/DD/YYYY) AD10120 Reimbursement is requested for expenses to accommodate a: (Please Select One) temporarily disabled employee ($1250 maximum) permanently disabled employee ($2500 maximum) Employee’s work restrictions and accommodation required (attach treating physician’s, QME or AME report, if not previously filed): Itemized list of costs for which reimbursement is requested (attach all receipts): 1. Modification to work site (list all work done and total cost) Cost 2. Equipment, furniture and/or tools (list each item and cost) Cost 3. Any other accommodation expenses: Cost (Attach additional sheets if necessary) DWC-AD form 10120 (SJDB) Rev: 11/2008 - (Page 2) AD10120 Total Costs: The above costs have not been paid for and are not covered by the insurance carrier or any other source. I declare that the information I have provided on this form is true and correct under penalty of perjury. Date (Signature of employer or employer’s representative) DWC-AD form 10120 (SJDB) Rev: 11/2008 - (Page 3) MM/DD/YYYY AD10120