INSTRUCTIONS The Answer must be filed within six days of service of the Application for Adjudication. The Answer may be used to object to the filing of the Application for Adjudication or the setting of proceedings, to request dismissal of the Application or other action, to respond to substantive issues raised in the Application, to correct inaccurate allegations in the Application, to raise affirmative defenses, and to request that additional issues be considered in the hearing. (Item 1) The answering party may object to filing of the application. Check appropriate boxes under Item 1 and explain reasons for objections. Attach additional pages if required, but clearly identify the objection you are discussing. (Item 2) The answering party may request dismissal of the application if it has already been filed. The reasons for the requested dismissal and the facts in support of it must be set forth. The reasons for dismissal in some circumstances may duplicate the reasons for objections to filing of the application. It is important that the Answer be as complete as possible. The information requested assists in the resolution of issues and settlement of dispute. 2002 © American LegalNet, Inc. STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD (This form is for injuries occurring on or after January 1, 1990) ANSWER OF CASE NO. (EMPLOYER, CARRIER, INJURED WORKER, DEPENDENT, LIEN CLAIMANT) (INJURED WORKER) (SOCIAL SECURITY NUMBER) (ADDRESS) (DATE OF ALLEGED INJURY) (APPLICANT IF OTHER THAN INJURED WORKER) (STATE) (ZIP CODE) (STATE) (ZIP CODE) (STATE) (ZIP CODE) (STATE) (CITY) (ZIP CODE) (ADDRESS) (CITY) (CORRECT NAME OF EMPLOYER; INDICATE IF SELF-INSURED) (ADDRESS) (CITY) (CORRECT NAME OF INSURANCE CARRIER OR, IF SELF-INSURED, ADJUSTING AGENCY) (ADDRESS) (CITY) 1. Answering party objects to the filing of the application for the following reasons: (EXPLANATION MUST BE PROVIDED FOR ANY BOX CHECKED. ) No bona fide dispute exists Efforts to resolve dispute not stated Medical reports and other documents indicating nature of dispute not attached to application Efforts to resolve dispute not made Medical reports alleged to have been served by applicant not received 14 days have not elapsed since claim form was filed and the employer has not denied or refused to pay benefits Other A claim form has not been filed with the employer A dated and completed claim form has not been attached to Application Explain: (See Instructions) (ATTACH ADDITIONAL PAGES IF NEEDED) 2. It is requested that the application, if filed, be dismissed for the following reasons: (See Instructions) 3. Other action requested (READ INSTRUCTIONS BEFORE FILLING OUT ANSWER - PRINT OR TYPE NAMES AND ADDRESSES) WCAB FORM 2 (4/1/90) (PAGE 1 OF 2) 90 56614 WCAB-2 2002 © American LegalNet, Inc. 4. Answering party denies the allegations of the application as indicated below with such explanations as are expressly set forth and admits all other material allegations. Medical-legal costs Employment Earnings Occupation Periods of disability Injury (Give last day worked and correct date of return to work) (If denial is based on date or part of body injured, please explain fully) Rehabilitation Insurance coverage (Check if employer has been notified to appear and defend) Permanent disability Liability for self-procured treatment (If apportionment is claimed, so state) Apportionment Liability for future medical treatment Other (ATTACH ADDITIONAL PAGES IF NEEDED) 5. IT IS FURTHER ALLEGED THAT THE FOLLOWING BENEFITS HAVE BEEN PROVIDED: Temporary disability indemnity in the total amount of $ through at the rate of $ per week beginning . Rehabilitation maintenance allowance in the total amount of $ rate of $ per week beginning in the total amount of $ at the rate of $ through . beginning at the Permanent disability indemnity through 6. Affirmative defenses and other matters: The right to raise additional issues in accordance with the provisions of law and the Rules of Practice and Procedure is not waived. I, , declare under penalty of perjury that the facts set forth under paragraphs 1, 2, and 3 are true and correct. Dated at , California, on , (Signature of answering party, attorney or representative) (Print or type) (Name of answering party, attorney or representative) (Address of answering party, attorney or representative) WCAB FORM 2 (4/1/90) (PAGE 2 OF 2) (Telephone number) 90 56614 2002 © American LegalNet, Inc.