STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ADJ APPLICANT V. DEFENDANT(S). PRE-TRIAL CONFERENCE STATEMENT §5502 (d) (3) NOTICE OF HEARING LOCATION: SETTLEMENT CONFERENCE JUDGE: APPEARANCES DATE: TIME: INJURED WORKER: INJURED WORKER'S ATTORNEY: ATTY HRG REP (FIRM NAME AND PERSON APPEARING) DEFENDANT'S ATTORNEY: ATTY HRG REP ATTY HRG REP ATTY HRG REP ATTY HRG REP (FIRM NAME AND PERSON APPEARING) OTHERS APPEARING: (DEFENDANT) (L.C., INTERPRETERS, ETC.) ADDRESS RECORD CHANGES: BOX BELOW TO BE COMPLETED ONLY BY WORKERS' COMPENSATION JUDGE WCAB NOTICE NOTICE WAIVED 1 HOUR 2 HOURS ½ DAY ALL DAY LIEN TRIAL BEFORE ANY WCJ BEFORE WCJ BEFORE ANY WCJ OTHER THAN CASE(S) SET ON AT WCJ IN (DATE) (TIME) (LOCATION) OTHER DISPOSITION AND ORDERS: DISPOSITION: SET FOR REGULAR HEARING: SERVICE AS ORDERED ON PAGE 4 WORKERS' COMPENSATION JUDGE WCAB FORM 24 (REV. 2013) PAGE 1 OF ___ American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ______________________ STIPULATIONS THE FOLLOWING FACTS ARE ADMITTED: 1. WHILE , BORN ______________ EMPLOYED ALLEGEDLY EMPLOYED ON DURING THE PERIOD(S) AS A(N) AT BY , OCCUPATIONAL GROUP NUMBER , CALIFORNIA, SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO CLAIMS TO HAVE SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO 2. AT THE TIME OF INJURY THE EMPLOYER'S WORKERS' COMPENSATION CARRIER WAS PERMISSIBLY SELF-INSURED THE EMPLOYER WAS UNINSURED LEGALLY UNINSURED 3. AT THE TIME OF INJURY, THE EMPLOYEE'S EARNINGS WERE $ RATES OF $ FOR TEMPORARY DISABILITY AND $ PER WEEK, WARRANTING INDEMNITY FOR PERMANENT DISABILITY. 4. THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: TYPE WEEKLY RATE PERIOD (TD/PD/VRMA) TYPE WEEKLY RATE PERIOD THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF T/D CLAIMED THROUGH 5. THE EMPLOYER HAS FURNISHED ALL SOME NO MEDICAL TREATMENT. THE PRIMARY TREATING PHYSICIAN IS 6. NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE ARRANGEMENTS HAVE BEEN MADE. 7. OTHER STIPULATIONS APPLICANT DEFENDANT LIEN CLAIMANT/OTHER WCAB FORM 24 (REV. 2013) PAGE 2 OF ___ American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ______________________ ISSUES EMPLOYMENT: INSURANCE COVERAGE: INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT: PARTS OF BODY INJURED: EARNINGS: EMPLOYEE CLAIMS EMPLOYER/CARRIER CLAIMS PER WEEK, BASED ON PER WEEK, BASED ON TEMPORARY DISABILITY, EMPLOYEE CLAIMING THE FOLLOWING PERIOD(S): PERMANENT AND STATIONARY DATE: EMPLOYEE CLAIMS ______________, BASED ON EMPLOYER/CARRIER CLAIMS ______________, BASED ON PERMANENT DISABILITY APPORTIONMENT OCCUPATION AND GROUP NUMBER CLAIMED: BY EMPLOYEE BY EMPLOYER/CARRIER NEED FOR FURTHER MEDICAL TREATMENT: LIABILITY FOR SELF-PROCURED MEDICAL TREATMENT: LIENS: LIEN CLAIMANT TYPE OF LIEN AMOUNT AND PERIODS PAID ATTORNEY FEES OTHER ISSUES: APPLICANT DEFENDANT LIEN CLAIMANT/OTHER WCAB FORM 24 (REV. 2013) PAGE 3 OF ___ American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT THIS PAGE FOR JUDGE'S USE ONLY JUDGE'S CONFERENCE NOTES: CASE NO. ______________________ ORDERS IT IS ORDERED PURSUANT TO WCAB RULE 10500, THAT DEFENDANT FORTHWITH THIS APPLICANT LIEN CLAIMANT SERVE PRE-TRIAL CONFERENCE STATEMENT NOTICE OF HEARING ON ALL PARTIES OR THEIR REPRESENTATIVE SHOWN ON THE OFFICIAL ADDRESS RECORD AND ANY ADDITIONAL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES (PAGE 3). IT IS FURTHER ORDERED THAT DEFENDANT APPLICANT LIEN CLAIMANT SERVE TIMELY NOTICE OF THE TIME AND PLACE OF ALL REGULAR HEARING SESSIONS ON ALL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES, TOGETHER WITH THE FOLLOWING NOTICE: YOUR LIEN IS AT ISSUE AND WILL BE ADJUDICATED AT REGULAR HEARING. IT IS FURTHER ORDERED THAT THE PROOF OF SERVICE ORDERED ABOVE BE FILED WITH THE WCAB ONLY ON REQUEST OF THE ASSIGNED WORKERS' COMPENSATION JUDGE. OTHER DISPOSITION AND ORDERS: SERVICE OF THIS DOCUMENT WAS MADE PERSONALLY UPON BY WCJ. DATE ______________ WORKERS' COMPENSATION JUDGE WCAB FORM 24 (REV. 2013) PAGE 4 OF ___ American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ______________________ EXHIBITS APPLICANT DEFENDANT LIEN CLAIMANT APPEALS BOARD DESCRIPTION DATE WITNESSES ABOVE LISTINGS OF EXHIBITS AND WITNESSES REVIEWED BY ALL PARTIES. APPLICANT DEFENDANT LIEN CLAIMANT/OTHER WCAB FORM 24 (REV. 2013) PAGE ___ OF ___ American LegalNet, Inc. www.FormsWorkFlow.com