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Application For Adjudication Of Claim (For Injuries Occuring On Or After January 1, 1990) WCAB-1 - California
| Application For Adjudication Of Claim (For Injuries Occuring On Or After January 1, 1990) Form. This is a California form and can be used in General Workers Comp . |
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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS SEE REVERSE SIDE FOR INSTRUCTIONS WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR ADJUDICATION OF CLAIM (FOR INJURIES OCCURRING ON OR AFTER JANUARY 1, 1990) ID OR CASE NO.: (READ INSTRUCTIONS BEFORE FILLING OUT APPLICATION - PRINT OR TYPE NAMES AND ADDRESSES) (INJURED WORKER) (ADDRESS) (DATE OF CLAIMED INJURY) (SOCIAL SECURITY NUMBER) (DATE OF BIRTH) (ATTORNEY FOR INJURED WORKER) (ADDRESS) (EMPLOYER) (ADDRESS) (INSURANCE CARRIER OR, IF SELF-INSURED, CERTIFICATE NAME) (ADDRESS WHERE CLAIM ADMINISTERED) (ADJUSTING AGENCY, IF ANY ADMINISTERED) (ATTORNEY FOR EMPLOYER/CARRIER) (ADDRESS) Venue selection based on: Labor Code Section 5501.5(a)(1) 5501.5(a)(2) 5501.5(a)(3) 5501.5(d) THIS APPLICATION IS BEING FILED BECAUSE A BONA FIDE DISPUTE EXISTS ON THE FOLLOWING ISSUE(S): Other Issues * MANDATORY ARBITRATION Contribution Insurance Coverage Permanent Disability less than 15% 20% Temporary Disability Medical Treatment Permanent Disability Reimbursement of Medical Expenses Rehabilitation Appeal (Rehabilitation Appeal must be attached to application) * (See Instructions - Parties may voluntarily agree to arbitration of any other issue(s)) Describe Nature of Bona Fide Dispute (See Instructions): IT IS CLAIMED THAT: 1. The injured worker, born (date of birth) , while employed as a (occupation at time of injury) on (date of injury) at (address) (city) (state) (parts of body injured) (zip code) by the employer sustained injury arising out of and in the course of employment to 2. The injury occurred as follows: (explain what employee was doing at the time of injury and how injury was received) 3. Actual earnings at time of injury: $ 4. The injury caused disability as follows: (specify last day off work due to this injury and beginning and ending dates of all periods off due to this injury. ) 5. Compensation was paid Yes No $ (total paid) $ (weekly rate) / / Yes No WCAB-1 2002 © American LegalNet, Inc. (date of last payment) 6. Unemployment insurance or unemployment compensation disability benefits have been received since the date of injury WCAB FORM 1 (REV. 2/91) (PAGE 1 OF 2) 7. Medical treatment was received Yes No (date of last treatment) Furnished by employer or carrier Yes No List physicians or hospitals not provided or paid for by employer (name of person or entity providing or paying for medical care) 8. Reports or records of the following physicians will be offered in evidence and are attached: (list by name and date) List all other medical reports (list by name and date) 9. The following other documents will be offered in evidence and are attached: 10. List other claims of industrial injury or applications filed by this injured worker: (If no application filed, attach copy or copies of Employee's Claim for Workers' Compensation Benefits (Form DWC-1) If application filed, give case number and location filed. ) NOTE: If additional space is needed to answer Items 1 through 10, attach additional pages to Application. DECLARATION UNDER PENALTY OF PERJURY I, the applicant, applicant's attorney or representative, declare under penalty of perjury that applicant has completed discovery; that all medical reports in my possession or control have been filed and served as required by the WCAB Rules of Practice and Procedure; that a copy of this application together with all supporting documents has been served on opposing parties (see proof of service attached); that applicant is ready to proceed to hearing mandatory arbitration voluntary arbitration on the issues indicated above; that the following efforts to resolve the issues have been made: and that applicant expects to present witnesses and I estimate the time required for the hearing will be hours. (If arbitration selected, Arbitration Submittal Form must be attached. ) Dated at (city) (date) , California (applicant's attorney or representative signature) (applicant's signature) (applicant's attorney or representative) (applicant's telephone number) (address and telephone number of attorney or representative) This Application may not be filed without a dated and completed Employee's Claim for Workers' Compensation Benefits form provided by the employer describing this claim of injury or disability. Attach copy of Employee's Claim for Workers' Compensation Benefits form. (See Instruction #1) WCAB FORM 1 (REV. 2/91) (PAGE 2 OF 2) 2002 © American LegalNet, Inc. INSTRUCTIONS Assistance in Filling Out Application You may request the assistance of an Information and Assistance Officer of the Division of Workers' Compensation. You also have the right to consult an attorney. Purpose of Application and When It Can Be Filed This Application for Adjudication of Claim is to be used to request a hearing before the Workers' Compensation Appeals Board or to initiate mandatory or voluntary arbitration. This Application for Adjudication of Claim is to be used for injuries occurring on or after January 1, 1990. (Labor Code Sections 5500 and 5275. ) This Application can be filed only after: 1) An Employee's Claim for Workers' Compensation Benefits (Form DWC-1 has been filed with the employee's employer and (a) 14 days have elapsed, or, (b) the employer or its workers' compensation insurance carrier has refused in writing to provide all or part of the benefits requested (Labor Code Section 4650). A dated copy of the completed Employee's Claim for Workers' Compensation Benefits provided by the employer must be attached to this Application (Labor Code Section 5401(b). If you need help filing or obtaining a copy of the Employee's Claim for Workers' Compensation Benefits, you can request assistance of an Information and Assistance Officer of the Division of Workers' Compensation. You also have the right to consult an attorney. You have obtained all of the medical reports and records and other documentary evidence on which you will rely at the hearing to prove your case and are ready to have the hearing. Copies of all such reports, records and other documentary evidence must be attached to this Application and listed in Items 8 & 9. This application and copies of all reports, records or other documentary evidence listed in Item 9 must have been served on the opposing party or parties before the submission of this Application for filing. You should keep a copy of all such documents for yourself. You have set forth the nature of the bona fide dispute as to the issues raised by indicating the benefit(s) cla
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