State of California Division of Workers' Compensation Workers' Compensation Appeals Board Arbitration Submittal Form Employee First Name: Last Name: Address/P.O. Box: City: State: Law Firm /Attorney Middle Initial: Zip Code: Employee Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: Non attorney Representative Middle Initial: State: Zip Code: Is the injured worker requesting arbitration or is the injured worker a party to the arbitration? List all the parties to this request for arbitration in the spaces provided below. Party Requesting Arbitration (If applicable) Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case number: Party Name: Address: City: State: Zip Code: Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: State: Zip Code: Middle Initial DWC-CA form 10297 Rev: 11/2008 Page 1 of 4 Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case Number: Party Name: Address: City: Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: State: Zip Code: Middle Initial: State: Zip Code: Law Firm /Attorney Non attorney Representative Party to the Arbitration Insurance Co. Self-Insured Party Name: Address: City: Legally Uninsured Uninsured Lien Claimant Case Number: State: Zip Code: Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: Law Firm /Attorney Non attorney Representative Middle Initial: State: Zip Code: DWC-CA form 10297 Rev: 11/2008 Page 2 of 4 Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case Number: Party Name: Address: City: Party Representative Law Firm : First Name: Last Name: Address/P.O.Box: City: State: Zip Code: Middle Initial: State: Zip Code: Law Firm /Attorney Non attorney Representative Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case Number: Party Name: Address: City: State: Zip Code: Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: Law Firm /Attorney Non attorney Representative Middle Initial: State: Zip Code: DWC-CA form 10297 Rev: 11/2008 Page 3 of 4 The issues below are hereby submitted for arbitration pursuant to Labor Code section 5275: Mandatory arbitration under Labor Code section 5275 (a) Insurance Coverage Contribution Voluntary arbitration under Labor Code section 5275 (b) Explanation of issues submitted for arbitration The parties have agreed to have this case heard before: Arbitrator Name Address: City: Phone Number: The parties have unsuccessfully attempted to agree on a arbitrator and request a list of arbitrators pursuant to Labor Code section 5271(b). The parties to the arbitration must sign this form in the spaces provides below. Dated: at , State: Zip Code: Party or party representative: Party or party representative: Party or party representative: Party or party representative: Party or party representative: DWC-CA form 10297 Rev: 11/2008 Page 4 of 4