SEE REVERSE SIDE FOR INSTRUCTIONS STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD CASE NO.: APPLICATION FOR ADJUDICATION OF CLAIM (DEATH CASE) (FOR INJURIES OCCURRING ON OR AFTER JANUARY 1, 1990) (READ INSTRUCTIONS BEFORE FILLING OUT APPLICATION - PRINT OR TYPE NAMES AND ADDRESS) (DECEASED WORKER) (ADDRESS) (DATE OF CLAIMED INJURY) (SOCIAL SECURITY NUMBER (APPLICANT) (ADDRESS) (ATTORNEY FOR INJURED WORKER) (ADDRESS) (EMPLOYER) (ADDRESS) (DATE OF BIRTH) (INSURANCE CARRIER OR, IF SELF-INSURED, CERTIFICATE NAME) (ADDRESS WHERE CLAIM ADMINISTERED) (ADJUSTING AGENCY, IF AGENCY ADMINISTERED) (ATTORNEY FOR EMPLOYER/CARRIER) (ADDRESS) Venue selection based on: Labor Code Section 5501.5(a)(1) 5501.5(a)(2) 5501.5(a)(3) 5501(a)(5) THIS APPLICATION IS BEING FILED BECAUSE A BONA FIDE DISPUTE EXISTS ON THE FOLLOWING ISSUE(S): Other Issues * MANDATORY ARBITRATION Temporary Disability Medical Treatment Permanent Disability Reimbursement of Medical Expense Rehabilitation Appeal Contribution Insurance Coverage Permanent Disability 20% less than 15% (Rehabilitation Appeal must be attached to application) * See Instructions - Parties may voluntarily agree to arbitration of any other issue(s)) Describe Nature of Bona Fide Dispute (See Instructions): IT IS CLAIMED THAT: 1. The deceased, born , while employed as a (date of birth) on (occupation at time of injury) (date of injury) at (address) (city) (state) (zip code) by the employer sustained injury arising out of and in the course of employment to (parts of body injured) resulting in death on . (date of death) 2. The injury occurred as follows: (explain what employee was doing at the time of injury and how injury was received) 3. Actual earnings at time of injury: $ 5. Compensation was paid 4. The injury caused disability as follows: ___________________ (specify last day off work due to this injury and beginning and ending dates of all periods off due to this injury) Yes No $ $ (total paid) 6. 7. (weekly rate) / . / date of last payment) Unemployment insurance or unemployment compensation disability benefits have been received since the date of injury Defendants have paid burial expense: Yes No Total Paid $ Yes No WCAB FORM 1A (REV 2/91) (PAGE 1 OF 2) 2002 © American LegalNet, Inc. 8. The employee left surviving him the following dependents: NAME 9. DATE OF BIRTH (if under 18) Medical treatment was received Yes RELATIONSHIP TO EMPLOYEE / No / . ADDRESS Furnished by employer or carrier Yes No (date of last treatment) List physicians or hospitals not provided or paid for by employer (name or person or entity providing or paying for medical care) 10. Reports or records of the following physicians will be offered in evidence and are attached: __________________________________ (list by name and date) List all other medical reports (list by name and date) 11. The following other documents will be offered in evidence and are attached: _____________________________________________ 12. List all other claims of industrial injury or applications filed by this injured worker: ________________________________________ (If no application filed, attach copy or copies of Employee's Claim for Workers' Compensation Benefits (Form DWC-1) If application filed, give case number and location filed.) NOTE: If additional space is needed to answer Items 1 through 12, attach additional pages to Application. DECLARATION UNDER PENALTY OF PERJURY I, , the applicant, applicant's attorney or representative, declare under penalty of perjury that the applicant has completed discover; that all medical reports in my possession or control have been filed and served as required by the WCAB Rules of Practice and Procedure; that a copy of this application together with all supporting documents has hearing mandatory been served on opposing parties (see proof of service attached); that applicant is ready to proceed to arbitration voluntary arbitration on the issues indicated above; that the following efforts to resolve the issues have been made: and that applicant expects to present witnesses and I estimate the time required for the hearing will be hours. (If arbitration selected, Arbitration Submittal Form must be attached.) Dated at ________________________________, California (city) (applicant's attorney or representative's signature) _______________________________________________ (date) (applicant's attorney or representative) (applicant's signature) (applicant's telephone number) (address and telephone number of attorney or representative) This Application may not be filed without a dated and completed Employee's Claim for Workers' Compensation Benefits form provided by the employer describing this claim or injury or disability. Attach copy of Employee's Claim for Workers' Compensation Benefits form. (See instruction #1) WCAB FORM 1A (REV 2/91) (PAGE 2 OF 2) 2002 © American LegalNet, Inc. INSTRUCTIONS Assistance in Filling Out Application You may request the assistance of the Information and Assistance Officer of the Division of Workers' Compensation. You also have the right to consult an attorney. Purpose of Application and When It Can Be Filed This Application for Adjudication of Claim is to be used to request a hearing before the Workers' Compensation Appeals Board or to initiate mandatory or voluntary arbitration. This Application for Adjudication of Claim is to be used for injuries occurring on or after January 1, 1990. (Labor Code Sections 5500 and 5275.) This Application can be filed only after: 1) An Employee's Claim for Workers' Compensation Benefits (Form DWC-1) has been filed with the employee's employer and (a) 14 days have elapsed, or, (b) the employer or the workers' compensation insurance carrier has refused in writing to provide all or part of the benefits requested (Labor Code Section 4650). A dated copy of the completed Employee's Claim for Workers' Compensation Benefits provided by the employer must be attached to this Application (Labor Code Section 5401(b).) If you need help filing or obtaining a copy of the Employee's Claim for Workers' Compensation Benefits, you can request assistance of an Information and Assistance Officer of the Division of Workers' Compensation. You also have the right to consult an attorney. 2) You have obtained all of the medical reports and records and other documentary evidence on which you will rely at the hearing to prove your case and are ready to have the hearing. Copies of all such reports, records and other documentary evidence must be attached to this Application and listed in Items 8 & 9. This Application and copies of all reports, records or other documentary evidence listed in Item 9 must have been served on the opposing party or parties before the submission of this Application for filing. Attach proof of service. You should keep a copy of all such documents for yourself. 3) You have set forth the nature of the bona fide dispute as to the issues raised by indicating the benefit(s) claimed or issue(s) raised and the reason for rejection or disagreement. (Labor Code Section 5500). 4) You have made good faith attempts to resolve the issue(s) for which you are requesting a hearing with the opposing party or parties (Labor Code Section 5500). You must describe in the Declaration Under Penalty of Perjury, the efforts you have made to resolve the issue(s) for which you are seeking a hearing. If the issue(s) raised in this Application are the subject of either mandatory or voluntary arbitration, you must check the appropriate box in the Declaration Under Penalty of Perjury and attach an Arbitration Submittal Form. The issues of contribution under Labor Code Section 5500.5 and insurance coverage must be submitted to arbitration. After January 1, 1991, the following shall be submitted for arbitration: Permanent disability where an informal rating has indicated that the permanent disability will be 15% standard or less, and the presiding judge determines that the case will not be set for hearing within 110 calendar days from the date of filing of the Application for Adjudication or where the informal rating has indicated that the permanent disability will be 20% standard or less, and the presiding judge determines the case will not be set for hearing within 150 days from the date of the filing of the Application for Adjudication. By agreement of the parties, any issue arising under Divisions 1 and 4 of the Labor Code may be submitted for arbitration. 5) You have completed all the blanks of the Application. Where information is unknown, place "Unknown" in the blank. If medical treatment is paid for by Medi-Cal, Medicare, group health insurance or private carrier, please specify. IMPORTANT IF ANY EMPLOYEE OR DEPENDENT IS UNDER 18 YEARS OF AGE, IT WILL BE NECESSARY TO FILE A PETITION FOR APPOINTMENT OF GUARDIAN AD LITEM. FORMS FOR THIS PURPOSE MAY BE OBTAINED AT THE OFFICE OF THE WORKERS' COMPENSATION APPEALS BOARD. THE PARTY PRODUCING A NON-ENGLISH SPEAKING WITNESS MUST ARRANGE FOR THE PRESENCE OF A CERTIFIED INTERPRETER. 2002 © American LegalNet, Inc.