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Supplemental Job Displacement Non-Transferable Voucher (On Or After 1-1-13) DWC AD 10133.32 - California
| Supplemental Job Displacement Non-Transferable Voucher (On Or After 1-1-13) Form. This is a California form and can be used in General Workers Comp . |
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SUPPLEMENTAL JOB DISPLACEMENT NON-TRANSFERABLE VOUCHER FORM For Injuries Occurring on or After 1/1/13 DWC - AD 10133.32 This is a supplemental job displacement non-transferrable $6,000 voucher for educated-related retraining and/or skill enhancement. It can be used to pay for education, counseling and/or training services. You can take this voucher to a California public school or to a state-certified provider on the Eligible Training Provider List, at http://etpl.edd.ca.gov and the school will be directly reimbursed upon receipt of a documented invoice by the claims examiner. You can also present this voucher to a counselor, which can be selected from the list on the Division of Workers' Compensation's ("DWC") website at: http://www.dir.ca.gov/dwc/SJDB/VRTWC_list.pdf. (First page to be completed by Claims Administrator) Employee Last Name Employee First Name MI Claims Administrator Claims Representative Claims Mailing Address City State Zip Code Claim No. Claims Phone Number Claims Email Address (optional) Date of Injury This voucher may be applied to any of the following expenses at the choice of the injured employee: (1) Payment for education-related retraining or skill enhancement, or both, at a California public school or with a provider that is certified and on the Eligible Training Provider List, including payment of tuition, fees, books, and other expenses required by the school for retraining or skill enhancement. (2) Payment for occupational licensing or professional certification fees, related examination fees, and examination preparation course fees. (3) Payment for the services of licensed placement agencies, vocational or return-to-work counseling, and résumé preparation, all up to a combined limit of $600. (4) Purchase of tools required by a training or educational program in which the employee is enrolled. (5) Purchase of computer equipment including, but not limited to monitors, software, networking devices, input devices (such as keyboard and mouse), peripherals (such as printers), and tablet computers of up to $1,000 reimbursable after cost is incurred and submitted with appropriate documentation. The employee shall not be entitled to reimbursement for purchase of games or any entertainment media. (6) Up to $500 as a miscellaneous expense reimbursement or advance, payable upon request (by submitting third page of this packet via email or regular mail) without need for itemized documentation or accounting. The employee shall not be entitled to any other voucher payment for transportation, travel expenses, telephone or Internet access, clothing or uniforms, or incidental expenses. Date Voucher Expires: This voucher must be used before it expires. American LegalNet, Inc. www.FormsWorkFlow.com DWC-AD form 10133.32 (SJDB) 1/2013 - Page 1 of 5 After this voucher expires, it will be unusable. All claims or expenses and reimbursement must be submitted to the claims adjuster before the expiration date at the bottom of the first page. If you will be using the services of a vocational return-to-work counselor, and/or training provider/school, please complete this page and mail it along with a copy of the first page to the claims administrator. (Second page to be completed by Employee) Vocational Return-to-Work Counselor (if any) (To Be Completed By Employee) Last Name First name MI Address: City: Phone State Zip Code Funds used for counseling (not to exceed $600): $ Training Provider or School Details (if any) (To Be Completed By Employee) Last Name First name MI Address: City: Provider Contact Name State Zip Code Training Cost: $ If you would like to request an advance and/or reimbursement on miscellaneous expenses (up to $500), please return page 3 to the claims administrator. If you would like to request reimbursement for computer equipment, tuition, fees, books, and/or tools, please return page 4 to the claims administrator along with documentation. If you pay for eligible expenses, you may be reimbursed for these expenses upon submission of documented receipts to the claims administrator for reimbursement. Reimbursement payments must be made by the claims administrator within 45 calendar days upon receipt of voucher, receipts, and documentation. If you decide to voluntarily withdraw from a program, you may not be entitled to a full refund of the voucher. If you choose to use the services of a vocational counselor, no more than $600 may be used for vocational or return-to-work counseling. The Injured Employee Must Sign and Date this Voucher Form Injured Employe Signature: Date MM/DD/YYYY If there is a dispute regarding this voucher, the employee or claims administrator may file Form DWC-AD 10133.55 "Request for Dispute Resolution before the Administrative Director." If you have a question or need more information, you can contact your employer or the claims administrator. You can also contact a DWC Information and Assistance ("I&A") Officer. Contact information for I&A can be found at: http:w.dir.ca.gov/dwc/ianda.html. DWC-AD form 10133.32 (SJDB) 1/2013 - Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR MISCELLANEOUS EXPENSES SUPPLEMENTAL JOB DISPLACEMENT NON-TRANSFERABLE VOUCHER FORM For Injuries Occurring On or After 1/1/13 DWC - AD 10133.32 Employee Last Name Employee First Name MI Claims Administrator Claims Representative Claims Mailing Address City State Zip Code Claim No. Claims Email Address Date of Injury The Injured Employee requests $500 as a miscellaneous expense reimbursement or advance. Injured Employe Signature: Date MM/DD/YYYY If you would like to request miscellaneous expenses, please complete this form and submit it to the claims adjuster. If an email address was provided, you can submit the Request for Miscellaneous Expenses (this form) via email; otherwise, please mail this form to the claims adjuster. If you are requesting reimbursement for the purchase of computer expenses, tuition, fees, books, and/or tools, please mail a Request for Reimbursement of Expenses (page 4) to the claims adjuster with appropriate documentation. Payments must be made by the claims adjuster within 45 calendar days of receipt of the request. You will not be entitled to any other voucher payment for transportation, travel expenses, expenses, telephone or Internet access, clothing or uniforms or incidental expenses. DWC-AD form 10133.32 (SJDB) 1/2013 - Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR REIMBURSEMENT OF EXPENSES
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