State of California Division of Workers' Compensation NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK FOR INJURIES OCCURRING BETWEEN 1/1/04 - 12/31/12, INCLUSIVE DWC - AD 10133.53 THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR (All information in this section must be completed): Claims Administrator Type: (Please Choose One) Insurance Company Third Party Administrator Employer Employer Name is offering you (Employee Name) the position of a Job Title You may contact concerning this offer. Phone No.: Date of offer: MM/DD/YYYY . Date job starts: MM/DD/YYYY Claims Administrator Claim Number : NOTICE TO EMPLOYEE (All information in this section must be completed) Name of employee: (Choose only one) a specific injury on First Name Last Name MM/DD/YYYY a cumulative trauma injury which began on (START DATE: MM/DD/YYYY) and ended on (END DATE: MM/DD/YYYY) Date of Birth: MM/DD/YYYY Date offer received: MM/DD/YYYY You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work. Regardless of whether you accept or reject this offer, the remainder of your permanent disability payments may be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you will not be entitled to the supplemental job displacement benefit unless: Modified Work or Alternative Work A. You cannot perform the essential functions of the job; or B. The job is not a regular position lasting at least 12 months; or C. Wages and compensation offered are less than 85% paid at the time of injury; or D. The job is beyond a reasonable commuting distance from residence at time of injury. DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com POSITION REQUIREMENTS (All information in this section must be completed) Actual job title: Wages: $ Per hour Week Yes Yes Yes Yes No No No No Month Year Is salary of modified/alternative work the same as pre-injury job? Is salary of modified/alternative work at least 85% of pre-injury job? Will job last at least 12 months? Is the job a regular position required by the employer's business? Work location: Duties required of the position: Description of activities to be performed (if not stated in job description): DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Physical requirements for performing work activities (include modifications to usual and customary job): Name of doctor who approved job restrictions (optional): Date of report: MM/DD/YYYY Date of last payment of Temporary Total Disability: MM/DD/YYYY Preparer's Name: Preparer's Signature: Date: MM/DD/YYYY THIS SECTION TO BE COMPLETED BY EMPLOYEE (All information in this section must be completed) I accept this offer of Modified or Alternative work. I reject this offer of Modified or Alternative work and understand that I am not entitled to the Supplemental Job Displacement Benefit. I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the Supplemental Job Displacement Benefit. Signature: I feel I cannot accept this offer because: Date: MM/DD/YYYY DWC-AD form 10133.53 (SJDB) 11/13 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO THE PARTIES If the offer is not accepted or rejected within 30 days of receipt of the offer, the offer is deemed to be rejected by the employee. If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director, Division of Workers' Compensation, P.O. Box 420603, San Francisco, CA 94142-0603. DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com