WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA Case No. Applicant VS. Petition to Terminate Liability for Temporary Disability Indemnity Defendants DEFENDANTS ALLEGE that the temporary disability was heretofore found by decision of this Board dated ; that temporary disability has been paid in the total sum of $ for the period to ; and that temporary disability terminated on , because (check appropriate box): (1) Applicant returned to work on said date (2) Applicant was declared able to return to work on said date per report of Dr. Dated (3) Applicant's condition is permanent and stationary as shown by attached medical report(s). (4) Other: Defendants are informed and believe that the applicant ______ presently working. Advances __________ being made on permanent disability indemnity at the rate of $ and will continue until approximately . per week Defendants request that the Appeals Board make an order terminating liability for temporary disability indemnity unless the employee objects, and if the employee does object, that this petition be set for hearing. All medical reports in petitioner's possession not previously served and filed herein, are attached hereto, served herewith, Insurer/Employer By _____________________________________________________________ NOTE: This form must be completely filled out and signed. NOTICE: Rule 10466 of the Board's Rules of Practice and Procedure reads in part as follows: "IF WRITTEN OBJECTION IS NOT RECEIVED TO THE PETITION WITHIN FOURTEEN DAYS OF ITS PROPER FILING AND SERVICE, THE BOARD MAY ORDER TEMPORARY DISABILITY BENEFITS TERMINATED, in accordance with the facts as stated in the petition or in such other manner as may appear appropriate on the record." Objections (see Rule 10466) should be address to the Appeals Board office located at (Insert address of local office) Copies mailed to the following on DIA/WCAB FORM 46 (REV. 5-75) DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS 2002 © American LegalNet, Inc.