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Request For Dispute Resolution Before Administrative Director DWC-AD 10133.55 (SJDB) - California
| Request For Dispute Resolution Before Administrative Director Form. This is a California form and can be used in EAMS Forms Workers Comp . |
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State of California Division of Workers' Compensation Retraining and Return to Work Unit REQUEST FOR DISPUTE RESOLUTION BEFORE ADMINISTRATIVE DIRECTOR DWC - AD 10133.55 Original Employer Accepted Claim Liability found by WCAB More than 60 Days Since TTD Ended Has PPD been stipulated, issued/ approved Claim Number Response SSN (Numbers Only) Employee (All information in this section must be completed) Case Number First Name MI Last Name Street Address /PO Box (Please leave blank spaces between numbers, names or words) City DOB Phone (Choose only one) a specific injury on MM/DD/YYYY State Zip Code MM/DD/YYYY a cumulative trauma injury which began on (START DATE: MM/DD/YYYY) and ended on (END DATE: MM/DD/YYYY) DWC-AD form 10133.55 (SJDB) Rev: 11/2008 - ( Page 1) 10133.55 Employee Representative (If Applicable) Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Employer (All information in this section must be completed) Insured Self-Insured Legally Uninsured Uninsured Name Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Employer Representative (if known and If applicable) Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Claims Administrator Information (if known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 2) State Zip Code 10133.55 Vocational & Return to Work Counselor (if applicable) Name Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City Phone State Zip Code Administrative Director Requested to resolve the following dispute because the parties disagree on (All information in this section must be completed): Employee's entitlement to a voucher. The parties dispute the amount of the voucher. The insurer has failed to pay training provider per title 8, California Code of Regulations sections 10133.57 and 10133. 58, and/or the VRTWC per title 8 California Code of Regulations sections 10133.57 and 10133.59. The employee objects to the new job duties provided by the employer. The employer objects to the amount of reimbursement approved or denied. Other Summary of informal efforts to resolve dispute Requester Name Date Signature DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 3) MM/DD/YYYY 10133.55
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