STATE OF CALIFORNIA WORKERS' COMPENSATION APPEALS BOARD ADJ Case # IMR Case # Applicant, Vs. PETITION APPEALING ADMINISTRATIVE DIRECTOR'S INDEPENDENT MEDICAL REVIEW DETERMINATION Defendants, A determination was made in the above-entitled case on __________________________________. The Applicant is aggrieved by said determination and hereby petitions for appeal of the administrative director's independent medical review (IMR) determination upon the following grounds: (Strike out items not applicable.) 1. The administrative director acted without or in excess of the administrative director's powers. 2. The determination of the administrative director was procured by fraud. 3. The independent medical reviewer was subject to a material conflict of interest that is in violation of Section 139.5. 4. The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability. 5. The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review pursuant to Section 4610.5 and not a matter that is subject to expert opinion. In support of the above, petitioner gives the following details, including a statement of each basis for objecting to the decision and a statement of all relevant facts upon which petitioner relies: WHEREFORE, Petitioner requests that the appeal of the administrative director's independent medical review determination be granted; further proceeding be had; and that decision be made to give petitioner all the benefits to which petitioner is entitled under the Labor Code of the State of California, including the relief requested herein. File this petition in the district office having venue. Attach the IMR determination, verification, and proof of service to this petition. D a t e d: Attorney (if any) for Petitioner Petitioner's Signature American LegalNet, Inc. www.FormsWorkFlow.com