California > Workers Comp > General
Notice Regarding Vocational Rehabilitation DWC-500I - California
|Notice Regarding Vocational Rehabilitation Form. This is a California form and can be used in General Workers Comp .||
|Get this form for FREE as a print-only pdf|
Date Employee Address City, State, Zip Date of Injury Claim Number Claims Administrator Address City, State, Zip Telephone Number Employer NOTICE REGARDING VOCATIONAL REHABILITATION (Claims Administrator) is handling your workers' compensation claim on behalf of (Employer). Since you have been off work for more than 90 days, under California law you have potential rights to vocational rehabilitation benefits. You may be eligible for these benefits if you are unable to return to your regular job duties. A job description, agreed to by you and your employer, must be submitted to your treating physician to help determine your ability to return to your regular duties. You will be notified of your treating physician's decision. Your prompt response and cooperation is needed to assist us in providing appropriate benefits. Only the items completed below concern your benefits at this time. You will soon be contacted by (Name or Company) to explain your potential eligibility for vocational rehabilitation services and to obtain information regarding your job duties. Enclosed is a blank job description form. Please complete and return the form to us as soon as possible. Your employer completed the enclosed job description. Please review the job description, make any corrections that need to be made, and return the form to us as soon as possible. Enclosed is a pamphlet explaining the vocational rehabilitation benefits that may be available to you. reading it carefully, please call me at if you have any questions. After The State of California requires that you be given the following information: If you want further information, you may receive recorded information by calling the State Information and Assistance Office at 1-800-736-7401 or call your local Information and Assistance Officer at . You may also consult with and be represented by an attorney. Sincerely, , Claims Examiner Enc.: Help in Returning to Work DWC Form RU-91 (blank) Applicant's Attorney Help in Returning to Work - '94 DWC Form RU-91 (completed by employer) cc: DWC 500-I 3/96 2002 © American LegalNet, Inc.