STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD STIPULATIONS WITH REQUEST FOR AWARD (Death Case) Case Number 1 Case Number 2 Venue Choice is based upon: (Completion of this section is required) County of residence of employee (Labor Code section 5501.5(a)(1) or (d).) County where injury occurred (Labor Code section 5501.5(a)(2) or (d).) County of principal place of business of employee's attorney (Labor Code section 5501.5(a)(3) or (d).) Select 3 Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet) Adult Dependent #1 Information First Name MI Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) City Adult Dependent #2 Information State Zip Code First Name MI Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code DWC-CA form 10214 (b) (Page 1) (REV. 11/2008) DWC-CA form 10214 (b) Adult Dependent #3 Information First Name MI Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Employer Information (Completion of this section is required) Insured Self-Insured Legally Uninsured Uninsured 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 State Zip Code Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator) Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code 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 State Zip Code DWC-CA form 10214 (b) (Page 2) (REV. 11/2008) DWC-CA form 10214 (b) The parties to the above-entitled action hereby enter into the following stipulations and request the Division of Workers' Compensation to issue Findings and Award forthwith, without further proceedings. IT IS HEREBY STIPULATED AS FOLLOWS: 1. That (First Name) (Last Name) , age (Years) , while employed at (Place of injury) as a (Occupation) by (Name of employer; an individual, co-partnership or corporation) on (Date of injury: MM/ DD/YYYY) sustained injury arising out of and occurring in the course of his/her employment, proximately resulting in the death of said employee on (Date of Death: MM/DD/YYYY) . That at said time, employer's workers' compensation insurance carrier , and both the employer covering said injury was and the employee were subject to the provisions of the Labor Code of the State of California. 2. That said employee left surviving him/her, wholly dependent/partially dependent, dependents listed herein: (Give name and if a minor, date of birth and relationship to the employee. Adult dependents are listed above and minor dependents are listed below.) Minor dependents Minor dependents? Minor Dependent # 4 Information Name Minor Relation Minor Dependent # 5 Information Date of Birth: MM/DD/YYYY Name Minor Relation Minor Dependent # 6 Information Date of Birth: MM/DD/YYYY Name Minor Relation DWC-CA form 10214 (b)(Page 3) (REV. 11/2008) Date of Birth: MM/DD/YYYY DWC-CA form 10214 (b) 3. That the said dependents are entitled to a death benefit of $ based upon earnings of $ (State weekly or monthly wages) , payable at $ a week. 4. That the sum of $ Total Sum Paid is payable to on account of the burial expense. The sum of $ has previously been paid to 5. That all necessary medical, surgical and hospital expenses on account of said injury has been paid by defendants. (If not paid, explain): Yes No 6. That defendants have heretofore paid the sum of $ on account of death benefit, for which they request credit. Total Death Benefits Paid 7. It is necessary that a guardian ad litem and trustee be appointed for the minors, and the parties request that First name Last Name be appointed such guardian ad litem and trustee. The Workers' Compensation Administrative Law Judge may assume that no attorney fee is involved in the above-entitled matter and should the facts be otherwise a detailed explanation shall be attached to these stipulations. Dependent or guardian signature (Date) Dependent or guardian signature (Date) Dependent or guardian signature (Date) DWC-CA form 10214 (b) (Page 4) (REV. 11/2008) DWC-CA form 10214 (b) Applicant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative First Name Last Name Law Firm Number Law Firm Name (Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Dated MM/DD/YYYY Applicant Attorney Signature Defendant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative First Name Last Name Law Firm Number Law Firm Name (Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Dated MM/DD/YYYY Defense Attorney Signature DWC-CA form 10214 (b) (Page 5) (REV.11/2008) DWC-CA form 10214 (b)