California > Workers Comp > General
Request For Expedited Hearing And Decision DWC-4 - California
| Request For Expedited Hearing And Decision Form. This is a California form and can be used in General Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA CASE NO. Applicant vs. REQUEST FOR EXPEDITED HEARING AND DECISION [LABOR CODE SECTION 5502(b)] Defendants The applicant herein, having filed an Application for Adjudication of Claim this date, requests that this case be set for expedited hearing and decision at on the following issues: Workers' Compensation Appeals Board Entitlement to Medical Treatment per L.C. 4600 Entitlement to Temporary Disability, or Disagreement on Amount of Temporary Disability Appeal from Decision and Order of Rehabilitation Bureau Entitlement to Compensation in Dispute Because of Disagreement between Employers and/or Carriers Explanation: APPLICANT STATES UNDER PENALTY OF PERJURY THAT THERE IS A BONA FIDE DISPUTE; THAT HE/SHE IS PRESENTLY READY TO PROCEED TO HEARING; THAT HIS/HER DISCOVERY IS COMPLETE ON SAID ISSUES; THAT THE TIME REQUIRED FOR HEARING WILL BE . Name (Print or Type) Signature of applicant Signature of attorney (if represented) Date: INSTRUCTION FOR FILING This request must be filed with an Application for Adjudication of Claim at the appropriate district office of the Appeals Board. SERVICE Type or print names and addresses of parties, including attorneys and representatives served with a copy of this request: DWC Form 4 (02/93) 2002 © American LegalNet, Inc. WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA CASE NO.: SOLICITUD PARA EXPEDIR LA AUDICION Y DECISION [CODIGO DEL TRABAJO SECCION 5502 (b)] Demandante Contra Demandado Eldemandante en esta, ha presentado una aplicacion para beneficios en esta fecha, el requiere que este caso sea dirigido para espedir la audicion y decision a Oficina de La Compensacion de Trabajadores de la Junta de Apelacion en los siguientes asuntos: Tener Derecho a Tratamiento Medico segun L.C. 4600 Tener Derecho de Incapacitado Temporal, o estar de desacuerdo con la cantidad de la Incapacidad Temporal Apelacion de la Decision y Orden del Bureau de Rehabilitacion Tener Derecho a recibir compensacion en Litigio por desacuerdo entre el Empresario y/o Compania de Seguros Explicacion: EL DEMANDANTE DECLARA BAJO MULTA DE PERJURIO QUE AQUI EXISTE UN LITIGIO DE BONA FIDE; QUE EL/ELLA ESTA AHORA PREPARADA PARA PROCEDER CON LA AUDICION; QUE SU DESCUBRIMIENTO ESTA COMPLETO CON LAS CUESTIONES DICHAS; QUE LA REQUERIDA HORA SERA Nombre (Escribe en letra de imprenta o maquina) Firma del Demandante Firma del Abogado (si es representado) Fecha INSTRUCCIONES PARA SER PRESENTADO Esta solicitud debe ser presentada con la Demanda de Adjuicio en una Oficina de Compensacion de Trabajadores. SERVICIO Escriba a maquina o en letra de imprenta los nombres y direcciones de las personas que hayan recibidos una copia de esta demanda, inluyendo los abogados y los representantes DWC Form 4 (2/93) DWC4-S 2002 © American LegalNet, Inc.
|
|||||||
