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Application For Adjudication Of Claim (For Injuries Occuring On Or After January 1, 1990) Form. This is a California form and can be use in General Workers Comp.
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Tags: Application For Adjudication Of Claim (For Injuries Occuring On Or After January 1, 1990), WCAB-1, California Workers Comp, General
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
SEE REVERSE SIDE
FOR INSTRUCTIONS
WORKERS' COMPENSATION APPEALS BOARD
APPLICATION FOR ADJUDICATION OF CLAIM
(FOR INJURIES OCCURRING ON OR AFTER JANUARY 1, 1990)
ID OR CASE NO.:
(READ INSTRUCTIONS BEFORE FILLING OUT APPLICATION - PRINT OR TYPE NAMES AND ADDRESSES)
(INJURED WORKER)
(ADDRESS)
(DATE OF CLAIMED INJURY)
(SOCIAL SECURITY NUMBER)
(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 ANY 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)
5501.5(d)
THIS APPLICATION IS BEING FILED BECAUSE A BONA FIDE DISPUTE EXISTS ON THE FOLLOWING ISSUE(S):
Other Issues
Temporary Disability
Medical Treatment
Permanent Disability
Reimbursement of
Medical Expenses
Rehabilitation Appeal
* MANDATORY ARBITRATION
Contribution
Insurance Coverage
Permanent Disability
less than 15%
20%
(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 injured worker, 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)
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: $
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. )
5. Compensation was paid
Yes
No $
$
(total paid)
/
(weekly rate)
/
(date of last payment)
6. Unemployment insurance or unemployment compensation disability benefits have been received since the date of injury
WCAB FORM 1 (REV. 2/91) (PAGE 1 OF 2)
Yes
No
WCAB-1
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7. Medical treatment was received
Yes
No
Furnished by employer or carrier
Yes
No
(date of last treatment)
List physicians or hospitals not provided or paid for by employer
(name of person or entity providing or paying for medical care)
8. 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)
9. The following other documents will be offered in evidence and are attached:
10. List 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 10, attach additional pages to Application.
DECLARATION UNDER PENALTY OF PERJURY
I,
the applicant, applicant's attorney or representative, declare under penalty of
perjury that applicant has completed discovery; 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
been served on opposing parties (see proof of service attached); that applicant is ready to proceed to
hearing
mandatory
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 signature)
(date)
(applicant's signature)
(applicant's attorney or representative)
(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 of injury or disability. Attach copy of Employee's
Claim for Workers' Compensation Benefits form. (See Instruction #1)
WCAB FORM 1 (REV. 2/91) (PAGE 2 OF 2)
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INSTRUCTIONS
Assistance in Filling Out Application
You may request the assistance of an 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 its 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. 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 information 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 Division 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 statement 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.
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