STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD CASE NO. APPLICANT V. DEFENDANT(S). PRE-TRIAL CONFERENCE STATEMENT §5502 NOTICE OF HEARING TIME: (e) (3) LOCATION: SETTLEMENT CONFERENCE JUDGE: APPEARANCES: DATE: 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: (L.C., INTERPRETERS, ETC.) ADDRESS RECORD CHANGES: (DEFENDANT) BOX BELOW TO BE COMPLETED ONLY BY WORKERS' COMPENSATION JUDGE DISPOSITION: SET FOR REGULAR HEARING: 1 HOUR 2 HOURS ½ DAY BEFORE ANY WCJ BEFORE WCJ CASE(S) SET ON AT (DATE) (TIME) ALL DAY WCAB NOTICE NOTICE WAIVED BEFORE ANY WCJ OTHER THAN WCJ IN (LOCATION) OTHER DISPOSITION AND ORDERS: SERVICE AS ORDERED ON PAGE 4 WORKERS' COMPENSATION ADMINISTRATIVE LAW JUDGE DWC CA form 10253.1 (Rev 9/2010) American LegalNet, Inc. www.FormsWorkFlow.com 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 THE EMPLOYER WAS PERMISSIBLY SELF-INSURED UNINSURED LEGALLY UNINSURED PER WEEK, WARRANTING INDEMNITY FOR PERMANENT DISABILITY. 3. 4. AT THE TIME OF INJURY, THE EMPLOYEE'S EARNINGS WERE $ RATES OF $ FOR TEMPORARY DISABILITY AND $ THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: WEEKLY RATE PERIOD (TD/PD/VRMA) TYPE WEEKLY RATE PERIOD TYPE 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. 7. NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE ARRANGEMENTS HAVE BEEN MADE. OTHER STIPULATIONS APPLICANT DEFENDANT LIEN CLAIMANT/OTHER PAGE 2 DWC CA form 10253.1 (Rev 9/2010) American LegalNet, Inc. www.FormsWorkFlow.com PRE-TRIAL CONFERENCE STATEMENT ISSUES EMPLOYMENT INSURANCE COVERAGE INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT PARTS OF BODY INJURED: EARNINGS: EMPLOYEE CLAIMS EMPLOYER/CARRIER CLAIMS CASE NO. 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 PAGE 3 DWC CA form 10253.1 (Rev 11/2008 9/2010) American LegalNet, Inc. www.FormsWorkFlow.com PRE-TRIAL CONFERENCE STATEMENT THIS PAGE FOR JUDGE'S USE ONLY CASE NO. ___________________ JUDGE'S CONFERENCE NOTES: 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 ISSUES SHOWN ON THE OFFICIAL ADDRESS RECORD AND ANY ADDITIONAL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER (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 THE ASSIGNED WORKERS' COMPENSATION JUDGE. ONLY ON REQUEST OF OTHER DISPOSITION AND ORDERS SERVICE OF THIS DOCUMENT WAS MADE PERSONALLY UPON BY WCJ. DATE _____/_____/_____ WORKERS' COMPENSATION ADMINISTRATIVE LAW JUDGE PAGE 4 DWC CA form 10253.1 (Rev 11/2008 9/2010) American LegalNet, Inc. www.FormsWorkFlow.com 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 PAGE ___ OF ___ DEFENDANT LIEN CLAIMANT/OTHER DWC CA form 10253.1 (Rev 9/2010) American LegalNet, Inc. www.FormsWorkFlow.com PRE-TRIAL CONFERENCE STATEMENT (MULTIPLE PARTIES) CASE NO(S) 1. APPLICANT, BORN , (1) SUSTAINED OR CLAIMS INJURY AS FOLLOWS: (2) (3) (4) CASE NO. DOI CLAIMS ADMITTED BODY PARTS JOB TITLE(S) OCCUPATIONAL GROUP NO(S). EARNINGS & TD/PD RATES EMPLOYER CARRIER ADJUSTED BY WORK COMP SECURED BY COVERAGE DATES INSURED SELF-INSURED UNINSURED CLAIMS ADMITTED CLAIMS ADMITTED CLAIMS ADMITTED INSURED SELF-INSURED UNINSURED INSURED SELF-INSURED UNINSURED INSURED SELF-INSURED UNINSURED 2. THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: TYPE WEEKLY RATE PERIOD PAID BY 3. 4. THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF TEMPORARY DISABILITY CLAIMED . THROUGH SOME NO MEDICAL TREATMENT. THE EMPLOYER HAS FURNISHED ALL THE PRIMARY TREATING PHYSICIAN IS . 5. 6. NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE AGREEMENTS HAVE BEEN MADE. OTHER STIPULATIONS: PAGE _____ DWC CA form 10253.1 (Rev 9/2010) American LegalNet, Inc. www.FormsWorkFlow.com