DIA WCAB FORM 10 (REV. 7/81) STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD ANSWER OF . Case No. (INJURED EMPLOYEE) Date of alleged injury: VS (CORRECT NAME OF EMPLOYER; INDICATE IF SELF-INSURED) (EMPLOYER'S ADDRESS AND ZIP CODE) (CORRECT NAME OF INSURANCE CARRIER OR, IF SELF-INSURED, ADJUSTING AGENCY) (INSURANCE CARRIER OR ADJUSTING AGENCY'S ADDRESS & ZIP CODE) ANSWERING DEFENDANTS deny the allegations of the application as indicated below with such explanations as expressly set forth and admit all other material allegations. DENIALS (Check box if allegation is denied) EXPLAIN BELOW Employment Occupation Injury (IF DENIAL IS BASED ON DATE OR PART OF BODY INJURED, EXPLAIN FULLY) Insurance coverage (CHECK IF EMPLOYER HAS BEEN NOTIFIED TO APPEAR AND DEFEND) Liability for selfprocured treatment Liability for future medical treatment Medical-legal costs Earnings Periods of disability (GIVE LAST DAY WORKED AND CORRECT DATE OF RETURN TO WORK) Rehabilitation Permanent disability (IF APPORTIONMENT IS CLAIMED, SO STATE) IT IS FURTHER ALLEGED: 1. Defendants have paid disability indemnity in the total amount of $ through plus at the rate of $ a week beginning . 2. Affirmative defenses and other matters: _________________________________________________________________________ Defendants do not waive the right to raise additional issues in accordance with the provisions of law and the Rule of Practice if other issues develop. Dated at __________________________, California, ___________________________ (EMPLOYER OR INSURANCE CARRIER) By: __________________________________________________________________ (ADDRESS AND TELEPHONE NUMBER OF ATTORNEY) 2002 © American LegalNet, Inc.