STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD ARBITRATION SUBMITTAL FORM (Print or type names and addresses; include ZIP Codes) Injured Worker Date of Claimed Injury Attorney for Injured Worker Employer Insurance Carrier or, if Self-Insured, Certificate Name Address ID OR CASE NO. Social Security Number Address Address Date of Birth Address Where Claim Administered Adjusting Agency, if Agency Administered Attorney for Employer/Carrier Party to Arbitration Attorney Party to Arbitration Attorney Address Address Address Address Address ISSUES (Attach additional pages if necessary): THE ABOVE ISSUES ARE HEREBY SUBMITTED FOR ARBITRATION UNDER LABOR CODE SECTIONS 5270, ET SEQ., ON THE FOLLOWING GROUNDS: Mandatory arbitration under Labor Code Section 5275(a) Voluntary arbitration under Labor Code Section 5275(d) ARBITRATION SELECTION IS REQUESTED AS FOLLOWS: Parties herein have agreed to have this case heard before Name of Arbitrator Address Telephone No. Parties herein have unsuccessfully attempted to name an arbitrator and hereby request arbitrator selection pursuant to Labor Code Section 5271(b). Dated at , California, on , . Party or Counsel/Representative WCAB FORM 32 (NEW 2/91) Party or Counsel/Representative WCAB-32 2002 © American LegalNet, Inc.